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April 30th, 2015

The Nepal Earthquake: A Harvard Fellow Shares Her Experience Near Everest Base Camp

Guest Blogger

Renee N. Salas, MD, MS, is a fellow in wilderness medicine in the Massachusetts General Hospital Department of Emergency Medicine. She is also an instructor of surgery at Harvard School of Medicine.

Renee Salas, MDDr. Renee Salas was working in a clinic below Mount Everest Base Camp when a 7.8-magnitude earthquake struck Nepal on April 25, 2015. She shares her perspective as an emergency responder.

It was just after noon, and my colleagues and I were in the living space of the Himalayan Rescue Association (HRA) clinic in Pheriche, Nepal, which is below Everest Base Camp. As realization set in about the events that were occurring, we ran outside to see nearly all of the buildings of the small village of Pheriche crumbling, at least partly. About a third were completely destroyed. In the midst of screams and dust clouds, we quickly circled the village after the earthquake vibrations had settled to see if anyone was injured. Amazingly, the only injury was small — a head laceration. If this disaster had occurred at night, I fear the injury rate would have been much higher. The village came together as everyone comforted one another and assisted those who had completely lost their houses. Some even began rebuilding their stones walls after the initial waves of aftershocks.

 

Nepal destructionDue to the severity of the damage and the strength of the earthquake, we were very concerned that the gravity of the event as a whole was severe. This was my first experience with an earthquake, and the severity of the earth’s movement was astounding. I felt as if I were on a boat at sea. The immediate thoughts and concerns were to the status of the families of the Nepali workers here and to our HRA colleagues in Everest Base Camp and Manang. Unfortunately, we had few means to gain credible information. We had been without internet contact for the preceding few days, and the internet remained inoperable. We attempted to reach Everest Base Camp with the radio system we had in place but were unsuccessful. Through conversations that my Nepali friends had with family and the HRA headquarters in Kathmandu, we learned that the earthquake had affected the city, but we had no understanding of the severity. We then began to assess the damage to the clinic, which had thankfully been limited to only a portion of the living quarters and left the patient treatment area unaffected. The numerous aftershocks we experienced caused the villagers to remain outside for a good portion of the day. Unfortunately, it was snowing with moderate winds, making the situation more difficult.

 

The first patients from Everest Base Camp were two climbing Sherpas who arrived about 9 hours after the earthquake, as they had immediately descended via foot and by horse. We saw and treated them — one was moderately injured and was admitted overnight and one with minor injuries was treated and released. We began to understand the gravity of what had occurred at Everest Base Camp as they recounted their experiences. We initially remained awake, believing that more would be arriving late that evening, but soon retreated to the sunroom (a free-standing building across from the clinic) to sleep given the continued aftershocks.

 

Nepal helicopterWe awoke the next morning, a little before 6 AM, to the sounds of helicopter traffic heading up the valley. We received word that all of the critically ill and wounded from Everest Base Camp would be evacuated to our facility, and we quickly began preparing for the possibility of significant patient volume. This is exactly the type of mass casualty situation that my emergency medicine and wilderness medicine training prepared me for. Our clinic has two inpatient beds, one consult room bed, and another extra bed in our research room. Our physician staff includes me, Andrew Nyberg from the U.S., and Katie Williams from the U.K. Meg Walmsley from Australia, one of the Everest ER physicians, descended via helicopter that morning to assist with the large patient influx. Gobi Bashyal, our clinic manager, leaped into action and began making phone calls to the surrounding areas and country officials to obtain the necessary manpower and helicopters, while Thaneshwar Bhandari, our assistant manager, began assisting us with preparations. We quickly mobilized the sunroom into a patient facility, and the owner of the Panorama lodge next door, whose lodge was one of just two that had been unaffected by the quake, graciously donated his dining room. We received approximately 10 critically ill patients first and placed them in the clinic and sunroom — many on makeshift beds placed on the floor. There was a mix of Nepalis and international patients. Approximately 20-30 more suffered major injuries and were unable to ambulate. I cared for the most critically ill patients in the clinic and sunroom. In total, we saw and evacuated an estimated 73 patients, including many “walking wounded.” We utilized disaster training and placed large white stickers on patients with their names, injuries, vital signs, and medication administration times. Our resources here include intravenous fluids, medications, and ultrasound. However, we are a remote post without access to blood products or the ability to perform subspecialty procedures that many patients required. Luckily, the weather cleared, and we were able to arrange further evacuation down to the hospital in Lukla, which had more resources. Numerous helicopters, including an MI-17 — which could hold 16-18 patients — made many trips as all patients were evacuated over a 5-hour period.

 

Nepal medicalThe local and international community here in the region came together in a way unlike anything I have ever experienced. Locals from the village and neighboring town of Dingboche assisted with transporting patients, arranging supplies, and giving patients and volunteers tea and food. International trekkers with nonmedical backgrounds who were in the region assisted selflessly with patient transport and donated first aid supplies and materials. We had numerous international physicians, nurses, and EMTs who spontaneously arrived and quickly set to work seeing patients, checking vital signs, and administering medications. When the last patient was evacuated, the nearly 100-200 people who had assisted all cheered and hugged one another for the amazing team effort… and then dispersed back to their villages while many international trekkers continued their descent to lower villages.

 

We have remained opened and will continue to see locals and trekkers until our job here is done. This likely won’t be until Everest Base Camp is cleared, and then we will convene with our Everest ER friends and colleagues and determine the next best course of action. Those descending from Everest Base Camp have shared their stories about their experiences on that fateful day, and we’ve tried to assist individuals as they attempt to learn about friends and loved ones. It has still been a very surreal situation that hasn’t truly hit home yet. There have been continued aftershocks that have served as jarring reminders that the danger is ongoing. Helicopter traffic has been constant between Everest Base Camp and Pheriche as climbers from Camps I/II and Everest Base Camp — and the bodies of the deceased — are evacuated.

 

Until we regained access to the internet yesterday evening, we had been in a vacuum with limited knowledge of the gravity of the situation within the remainder of this amazing country that has become our home for the past 2 months. This is a country full of loving people, and the innately welcoming culture has created a collaborative and selfless post-disaster environment here in the Khumbu Valley. However, this is a country with very limited resources. We spent the first week of March in Kathmandu for orientation before our acclimatization trek here, so I know parts of the city well. The situation in Kathmandu sounds grave as medical facilities have been quickly overwhelmed and they have struggled to take care of patients in damaged buildings and in the continued wake of aftershocks. The situation in the more remote outlying villages is unknown. As food and water resources dwindle and the lack of sanitation grows, risk for epidemics is high — which will turn an already dire situation into a nightmare. The country will require basic needs such as food/water and medical and infrastructure personnel and supplies. Any assistance, depending on your resources and abilities, would be greatly appreciated, including prayers. Similar to the Haiti earthquake aftermath, in which I participated, this will be a marathon and not a sprint as further pitfalls lie ahead as we attempt to rebuild this country. As I have limited knowledge of the true situation in Kathmandu, I cannot speak to specific needs currently, but these will become clear as time progresses and especially when I descend to the city in the coming 1 to 2 weeks.

Nepal site

 

April 10th, 2015

Being Taught to Be a Teacher

Guest Blogger

Guest Blogger: Jenna Kay, MD, is a Chief Resident at Emory University Hospital. She will be starting her cardiology fellowship in July, 2015.

How to insert a central line had been drilled into me long before my first attempt, and I was admittedly nervous performing my first procedure as an intern. But, as a senior resident, watching the intern in front of me insert his needle into the patient’s neck was 10 times more anxiety-provoking. I wanted to guide him successfully through the first of many procedures he would need to master, in the same way my senior resident had guided me. I fought a strong temptation to take over entirely. By now, I could do a central line in my sleep. But teach one? I hadn’t given it much thought until that moment.

Doctor consults with patient

from the National Cancer Institute, an agency part of the National Institutes of Health: ID 4544

Medical trainees are provided an extraordinary amount of resources geared toward helping us learn. Beyond experiential learning, we have journals, meetings, webinars, textbooks, virtual interactive cases — just about any imaginable resource for every kind of learner. The opportunities to learn how to teach, however, are a smaller portion of the curriculum and a relatively new area of focus for medical institutions. Before I stood behind my intern that day, I was entirely focused on my own learning. But in that instant, my emphasis shifted: Did I have the necessary skill set to teach? As an aspiring academic clinician, I was hungry for those resources.

In the final month of my intern year, we attended a session with experienced faculty who advised us on effectively leading a team, engaging trainees at different levels, and giving constructive feedback. It all rang true, based on my experience as a learner, but I still felt hesitant to jump in. Teaching seemed to be an immense responsibility that humbled me before I even started.

On my first day as a chief resident, I sat at a pristine desk with a full candy jar and plenty of tissues, but… lead morning report? Me? I was excited by the theoretical possibility of becoming a better teacher but also full of self-doubt and reluctant to ask for help. Did I really want to ask someone to watch me lead a noon conference, or teach aspects of the physical exam that I myself had mastered only incompletely? The answer was no — I did not want to subject myself to scrutiny and judgment in front of an evaluator. But the answer was also an overwhelming yes, because I could see how much potential for growth lay ahead if I could push past my ego.

As part of our faculty development program, I signed up for a teaching mentor. He was full of ideas. We agreed that he would sit in on conference and watch me lead rounds; I made plans to shadow him with his team. I started to recognize and accept other opportunities to teach that I had assumed were only for “real” teachers, and I made a point to ask for feedback, painful as it sometimes was. Hands down, the hardest part was making the decision to ask. Once I took the plunge, I always gained perspective and felt inspired about what to try next.

Now my eyes are wide open, and experience has opened the door to bravery. I’ve been able to take advantage of many teaching opportunities and have started to create a personalized teaching blueprint. When residents come to my office asking for advice on teaching, guiding them is one of the highlights of my job.

Jenna Kay, MD

February 17th, 2015

Barriers

Priya Umapathi, M.D.

brick wallIn an era of near-instantaneous transmission of data, where multi-billion dollar financial transactions are completed in the blink of an eye and where the worldwide web will answer any question in less than 0.19 seconds, communication during patient encounters remains a thorny issue.

 

One recent afternoon, I saw Mrs. D in the medicine clinic. She originally had a 9 am appointment to (among other things) check her INR. She misunderstood the need to have her blood drawn prior to the visit but was directed to have blood work done and to return to be seen in the afternoon. When she arrived, we chatted as I worked my way down a seemingly endless list of primary care to-do’s and focused problem assessments. Having reviewed and communicated the significance of pertinent lab work and imaging, reconciled and e-prescribed medications, counseled her on smoking cessation/weight loss/exercise/low-salt diet, and made appropriate referrals, I considered it a successful 45-minute visit (yet well over my allocated scheduled time). I hurriedly explained medication adjustments I had made, bid Mrs. D farewell, and raced to grab my next patient’s chart.

It was a busy clinic day, and we ended late. While walking back to the hospital, I saw Mrs. D in the clinic waiting area. My heart sank. She looked so tired. She said she was waiting for a ride home. The medical transportation she had set up to take her back was for the morning, and the company would not reschedule. She hated being a burden on her kids, but she had swallowed her pride to call her daughter to ask for a favor. Tears started flowing as she said she had been waiting for me to finish so we could talk. She had tried to pick up insulin at her pharmacy, but I had prescribed Novolog, and her insurance carrier would only cover Humalog unless they received physician pre-approval. She had stayed in the waiting room for longer than an hour, waiting for me, because she was scared to go home without insulin or to navigate our labyrinthine resident clinic phone system to reach me. It took less than 3 minutes for me to reach, and speak with, the pharmacist to release her insulin. Overall, her time spent for a follow-up medicine visit and prescription pick up? 6 hours and 3 minutes

Our medical students take semester-long courses on effective doctor–patient communication. In residency, we have formal and informal discussions centering on cultural competency, identifying disparities in health literacy, and answering as basic a question as “can your patient read?” But sometimes, despite our best intentions, the challenges in delivering patient care are not apparent. We race through gathering, assembling, and synthesizing all the information present in an electronic medical record that is bloated with myriad notes, evaluations, medications, images, and lab information. (Don’t get me wrong! I can’t count the number of times I have been grateful for an EMR, especially at 2 am, while trying in vain to decode a consultant’s cryptic scribble). But our need to parse this data to help synthesize our treatment plans is time-consuming. Certainly, it is useful to review a trusted colleague’s prior note about the patient in front of you, but no amount of searching the record provides knowledge of the patient’s family, finances, or access to transportation.

A question to consider: How many of your patients neglect their preventive and follow-up care because it might jeopardize their jobs? Do you know?

How do we navigate a bulky healthcare delivery system that includes charges from managed care organizations, HMOs, and private insurers and costs for the private payer and still provide patients with the care they require? The interplay between these components and the need for their symbiosis for healthcare delivery is too complicated for even the most robust EMR. Residents and patients in a busy primary care clinic can feel both overwhelmed and underserved. New (and not-so-new) physicians have a limited knowledge of the complicated system that regulates what care patients have access to and of how to facilitate efficient treatment in an environment centered on cost (not necessarily care). The challenge of keeping patients at the center in a rapidly evolving healthcare environment remains.

One of my wisest clinic preceptors always underlined two things: the need to prioritize problems and the power of good conversation. I would argue that ticking check boxes for every screening recommendation and medical item over the span of a few visits, instead of cramming them all into one encounter, is a far better use of time. Learning that your patient can’t make a screening colonoscopy appointment because he doesn’t have transportation is more efficient than referring him multiple times without ever addressing the real problem. Turning away from your computer and talking to your patient (and not just about his diseases) initially might feel far less productive, but a few carefully chosen questions in fact could be the single best way to ensure your patient’s health.

As healthcare professionals, we have to connect with and understand our patients. Only then can we be successful at treating them.

 

December 22nd, 2014

Thinking Introspectively About the Holidays

Priya Umapathi, M.D.

https://www.flickr.com/photos/mkosut/

Photo by Mackenzie Kosut, June 15, 2009

In the midst of the holiday season, nestled as we are between Thanksgiving and New Year’s, I find myself in a reflective frame of mind. December marks the end of the year, and it harkens new beginnings on the horizon — and I find myself transitioning to new phases of my training. Some readers might find this post to be very introspective, but I thought it apt given the recent completion of many fellowship matches, including my own.

My self-reflection began in earnest this past summer. The confluence of being a chief resident, taking the ABIM and applying for fellowship mandated a time-sensitive and earnest appraisal of my abilities, dedication, and professional and personal goals.Like many of my co-fellowship applicants, my choice of subspecialty was a field that resonated with me and had inspired me to commit much of the past 3 years of my life to get to this point. We probably have all asked ourselves why we chose a particular field and what attributes made us best suited to pursue specific fellowship training. These answers, and the efforts made to attain them, distill into a personal statement. Amidst the flurry of activities I undertook to be a competitive candidate, I was forced to pause, to think, and to remember. Taking stock of not only who I am, but also how I had come to this stage in my career. Revisiting the whos, whens, whats, and whys of a lifetime of choices and experiences that led me to the present was a welcome epiphany. The rapid pace of daily life and myriad items that require immediate action seldom offer an opportunity to experience the richness that comes from reflection. Although challenging, periods of transition offer us opportunities to reflect, to understand, and — most importantly — to make peace with ourselves.

As my fellowship interview season came to an end, our residency interview season had just begun. I have been fortunate to gain another perspective, now from the other side of the proverbial “desk”. I am honored to have a window into the lives of those walking the path I took just 4 years earlier. In interviewing applicants, I am able to trace their journeys among schools, jobs, and even continents. Learning about their struggles and hearing about their successes serves to remind me of my own journey and challenges on the road to residency. We have all been challenged and struggled in different ways, but we are bonded in our shared medical training experience. Perhaps, in this, there is that proverbial sense of professional identity that allows us to empathize and relate to each other. The interview process has allowed me to continue to grow and mature, and has provided me with a greater understanding of myself and my connection to my colleagues.

The lessons learned personally and by proxy have humbled me and strengthened me and made me more resolute — both in who I am and in what I hope to be. These reminders of past efforts, successes, and failures don’t dampen or deter current success; in many ways, they serve to accent the beauty of the present and mark our arrival point. This Thanksgiving, I have many things in my life to for which to BE thankful, and the opportunities to reflect during the past year have brought much warmth and richness my way. My New Year’s resolution is to take more time to reflect on the past. A little introspection goes a long way! Happy Holidays!

October 6th, 2014

Introducing Myself

Priya Umapathi, M.D.

Rutgers University HospitalHello! I’m excited to have an opportunity to share my adventures, experiences, and opinions from chief year with you. Transitioning between life phases can be traumatic at times, but invariably bears great potential for exponential self–growth. This year, so far, has confirmed that there is indeed much growing to be done! We held a transition event for our house staff prior to the beginning of this academic year, which I affectionately dubbed “Metamorphosis” (I know, corny), to discuss some of the expectations, roles, and responsibilities associated with becoming a senior resident. The many themes of the night included incorporating enthusiasm, intellectual curiosity, and compassion into our daily lives to become more effective leaders. I watch my new senior residents draw on these attributes daily as they navigate their way through managing patients and teams independently. We face an ever-changing landscape of medicine with challenges in implementation of healthcare reform, the work hour debate on resident and patient outcomes, the financials of medical school costs relating to choices for specialties, and the rise of genetically personalized healthcare, to name a select few… The adage, “may you live in interesting times,” has never been more apt! My hope is that I will be able to incorporate themes from our Metamorphosis event into my year as chief and look forward to sharing insights with you about both my personal and professional growth.

October 6th, 2014

NEJM Journal Watch Welcomes Priya Umapathi, MD

Charleen Hamilton

The editors and staff of NEJM Journal Watch welcome Dr. Priya Umapathi as our new Chief Resident blogger. Priya will be sharing her experiences as a teacher and mentor at Rutgers.

April 28th, 2014

Cynicism in Medicine

Akhil Narang, M.D.

WachterICUforWeb_bigger“Are you more or less cynical than when you started residency?” This was the question my Program Director asked our senior internal medicine residents at a recent dinner with Dr. Bob Wachter. If you aren’t familiar with Dr. Wachter, he is widely acclaimed as the “Father of Hospital Medicine” and a renowned champion of patient safety and quality. His blog, Wachter’s World, is chock full of insightful commentary on the American healthcare system, written with levitating optimism. In a time where criticism of doctors and hospitals (coupled with pessimism reflecting the country’s healthcare system) is trendy, Dr. Wachter’s breath of fresh air is welcoming. It got my Program Director thinking about cynicism in medicine and inspired this post.

The 30-odd residents, months shy of graduating, got an opportunity to answer whether they viewed themselves as more or less cynical than at the start of their residency training. Many of responses reflected increased cynicism toward “the healthcare system.” When pressed to explain further, many answers stemmed from the frustration they feel when taking care of patients: difficulty in establishing primary care follow-up for the uninsured, inability to get antibiotics covered by insurance, administrative red tape of setting up home oxygen therapy, and even the cumbersome process of obtaining outside hospital records. It was refreshing, however, to hear residents qualify their cynicism. More often than not, residents did not single out cynicism toward patients as much as they did toward the system. If we are to continue producing generations of passionate and dedicated physicians who don’t burn out, we need to start addressing ways to deal with cynicism.

Short of nationwide reform, hospitals and residency programs can play a part in helping to shape (arguably) the most pliable time in a young physician’s career. While it’s certainly character building to be able to successfully navigate filling out nursing home transfer forms, finding a means to get a patient’s INR checked, making follow-up appointments, and calling insurance companies to plead for antibiotic approval, this type of work should not dominate the daily cycle of residency. There is little doubt that “scut work” helps us better understand the bureaucracy and red tape associated with our healthcare system, but it also unequivocally takes away from a plethora of formal educational opportunities and it contributes to violations of strict duty-hour regulations.

In speaking to my colleagues around the county, I have found that hospitals and residency programs provide variable support to their housestaff: some of the best programs offer dedicated resident assistants (typically PAs) and streamlined workflows for discharging patients (multidisciplinary rounds, discharge planners to schedule appointments). Residents who were the least cynical in my unscientific polling were those who had the most resources at their disposal. I wonder if, down the line, the less cynical residents become less cynical fellows and subsequently less cynical attendings. I wonder if these physicians experience less burn out than their colleagues whose training programs do not equip them to navigate the healthcare maze.

Recognizing that all hospitals and programs are not created equal and that perks such as PAs or discharge coordinators are luxuries that many hospitals aren’t in a position to provide, addressing the larger issue of cynicism in medicine is important. A certain degree of cynicism is healthy but when cynicism borders on indifference or complacency, we’re in trouble. To effectively curtail cynicism directed at the “system,” hospital leadership needs to engage their residents. For many hospitals, residents provide the greatest amount of hands-on patient care. Residents are often the first and last providers that patients encounter during hospitalizations. Every hospital recognizes the importance of quality improvement and creating lean workflows; resident input and feedback should be solicited at every step of the way. Concerted efforts to address issues that plague residents (whether it be better social work support or a lack of computers) should be taken seriously.

Residents need to feel empowered by their programs and hospitals to make changes. Whether those changes are major or minor, a collaborative effort between housestaff and hospitals will inevitably be well received. Unilateral decision-making (especially if controversial) can lead to significant resentment and to worsening cynicism. I have no delusions that once residents and fellows finishing their training, challenges in their practice environments (academics, private practice, or industry) certainly can augment cynicism. Nonetheless, if the formative years of one’s training are optimized, scores of physicians might enter their post-training careers with a less cynical mindset.
So now I ask you to reflect on your experiences. Are you more or less cynical than when you started your residency training? If you’re more cynical, why and how much of this was a result of modifiable factors in your training program?

Follow Dr. Akhil Narang on Twitter @AkhilNarangMD

April 5th, 2014

Learning to Unlearn and Other Advanced Skills

Paul Bergl, M.D.

In my transition from pure learner (i.e., the med student role) to teacher-learner (i.e., the attending), I’ve actually found myself focusing more on the learner than the teacher part of my dual existence.  Strong learning seems to be requisite to strong teaching, and I am realizing that succeeding on the next level requires some extra meta-cognition, that is, learning to learn in new ways.

Learning to Unlearn 

In med school, learners amass an incredible amount of new information and master a completely new language. Suffice it to say that “drinking from the firehose” probably understates the reality of undergraduate medical education.

Our schools inculcate lots of so-called “facts” into our students’ fresh minds, and said students suck up these facts like infinitely absorptive sponges. Sure, students often purge the data after cramming for tests, but they inevitably reclaim much of this knowledge over the next several years. And thus, students graduate medical school with their minds encumbered by extraordinary amounts of information to apply to patient care.

This approach unfortunately is faulty in two respects: Memory is imperfect, and facts are not immune to mutability. I have been caught on rounds reciting “facts I learned in medical school” only to have my team discover that almost no reputable sources can corroborate my claims — or even worse, that a reputable source completely refutes them. I cannot always pin down the etiology of my misinformation. I usually blame time’s effect on the faulty memory compartment. More importantly, I make a mental note to condemn that parcel of my brain and vacate it for future use.

My advice: Actively seek out the misinformation in your brain, and purge it. Identify what you thought you’ve learned but isn’t true.

Learning to Get Answers Without the Certainty of an Answer Key

As learners progress through their undergraduate and graduate training, they move from the black-and-white world of correct answers to a landscape of gray zones devoid of an answer key. Students often live and die by “what’s going to be on the test.” Even residents living in the oft-ambiguous world of clinical medicine have some anchor of certainty: the attending’s final word. No matter what shade of correct or incorrect a clinical decision is, the resident can often fall back on what the attending will want.

When there is no longer a judge of correctness — be it the professor, the course director, or the attending – it can be quite unnerving. In this situation, the teacher-learn should remember that “facts” you’ve learned are never truths. They are half-truths with varying degrees of evidence that can be variably applied to actual clinical scenarios.

My advice: When faced with situations where a correct answer cannot be known, gather all the information you can to make an informed decision. Remember that the teacher-learner becomes a de facto answer key, but be ready to adjust the grading rubric too.

Learning to Learn Critically

The learner role affords a certain luxury to students and residents: leaving all the critical thinking to the experts. For example, when you rotate on your cardiology rotation, you must recite gospel verses like, “Give an ACE inhibitor and β-blocker for everyone with reduced ejection fraction.” But what about that latest study on angiotensin receptor neprilysin inhibitors? Well, you get to leave the interpretation and its application to real-life settings to the renowned cardiology attending.

I am not saying that residents aren’t expect to think critically. But they often don’t have the time to learn critically: to analyze the latest developments and consider how to integrate the evidence into practice. Instead, students and residents defer or default to the experts (and integrate this information as “facts” into their brain; see sections above).

Now imagine what happens when no expert is present. The teacher-learner needs to be prepared to face situations in which he or she might be the one distilling very complicated data into spoon-fed “pearls.” The teacher-learner also needs to decide how much stock to put into his or her own truths.

My advice: Imagine how you would apply newly acquired knowledge to your patients before actually doing so. Someday you will not have an expert to lead the way, and you never know when your trainees might look to you for guidance.

Follow Dr. Paul Bergl on Twitter @PaulBerglMD

February 11th, 2014

Do Quality Initiatives and the Patient Safety Movement Threaten Resident Autonomy?

Paul Bergl, M.D.

sign of the times

A sign of the times?

Recently, our residency program had the excellent fortune of hosting Dr. Bob Wachter as a visiting speaker. Dr. Wachter is considered a pioneer in the hospitalist movement and has built his career around inpatient quality and safety. During lunch with Dr. Wachter, some of our residents, and hospitalist faculty, we discussed the topic of resident autonomy in the hospital. In the glory days of residency, I imagine that house officers experienced autonomy in its truest sense of the word: self-rule and utter independence. At least that’s the impression I have from Stephen Bergman’s (a.k.a Samuel Shem’s) House of God … a Lord of the Flies–like island inhabited by unsupervised and uninhibited junior physicians.

We all know that the 21st century’s inpatient environment leaves less room for such resident independence — and shenanigans, for that matter. Through regulatory and advisory bodies, patient advocacy groups, and our own recognition, we are now rightly focusing on other domains of hospital care. The main priority is not to “just let the doctors take care of patients how they want.” With this sea change, resident autonomy has evolved accordingly — both in practice and as a concept.

In case you haven’t heard, the quality and safety era is here to stay. Because true autonomy and “learning by doing” can potentially stand squarely at odds with quality metrics and the safest possible outcomes, I have to wonder:

  • Will resident autonomy disappear completely in the future?
  • How has autonomy changed already?
  • And how will trainees learn to practice independently with all of this change?

Anyone that works in graduate medical education knows that duty-hour reform fundamentally shook the resident learning experience and thus affected autonomy. Since the additional 2011 duty hours changes were enacted, teamwork has become the name of the game. Residents routinely are forced to pass off decisions or depart before the implications of their decisions materialize. Attending physicians now seemingly shoulder more of the clinical workload, too, when residents’ shifts are truncated by a requirement to leave the hospital.

There is also probably universal agreement that the imperatives to reduce hospital length of stay and to facilitate safe discharges affect resident independence. As an attending, I know the pressures that the hospital is under, and I often feel compelled to be very directive about making prompt discharge a reality.

I doubt that residents would feel that either of these changes has eliminated their autonomy completely. Often in medicine, there is no single correct way to achieve an end. For this reason, residents can still safely be given leeway in many clinical decisions. There is still some art in what we do, and autonomy lives to see another day. But there are looming changes on the horizon that might threaten resident autonomy even more. Those that spend time in the hospital training environment recognize that all participants in inpatient care will increasingly be measured by how well they do their jobs. It is hard to conceive of a system in which residents and the attendings that supervise their care will be spared from aggressive quality improvement.

The stakes are simply too high nowadays. Health care is expensive and still unacceptably unsafe and unhelpful. With mounting pressures to provide higher value care, residents’ decisions are likely to undergo more scrutiny. Why is Resident A ordering more CT scans than Resident B? Why are Resident C’s patients staying in the hospital 2 days longer than Resident D’s? In my own experience as a chief resident, I know that residents still want autonomy. Heck, autonomy was my top priority in evaluating residency programs myself. As I have interviewed and met a number of applicants to our program during this residency match season, I sense that soon-to-be trainees are also putting autonomy high on their list of values. I like to tout my program’s emphasis on autonomy. I try to foster resident growth while attending on service by relaxing the reigns. I know the term autonomy doesn’t mean what it once did. Yet I do have hope that we can still give residents the leeway to “learn by doing” while preserving the health of the patients we serve and the financial stability of our healthcare system and our country.

January 13th, 2014

Reflections of a New Attending

Akhil Narang, M.D.

During my year as a Chief Resident, I have the privilege to attend on the general medicine service for 8 weeks. I recently completed 4 weeks and, as expected, found myself in an entirely new realm of patient care and accountability. I would be remiss without recalling a few of the pivotal lessons and poignant moments that stand out.

Transitioning from resident to attending inevitably results in greater scrutiny. Despite my best efforts to prevent readmissions (especially within 30 days), I had several during my first month. A cirrhotic patient with a recurrent variceal bleed, a patient with sickle cell disease readmitted for a vaso-occlusive crisis after a sharp overnight temperature drop, and an older nursing home resident treated for a UTI who came back for seizures. Given the mounting pressure to prevent readmissions, I spent numerous hours dissecting the chart for each patient attempting to understand what went wrong and what I could have done differently. I discussed the cases with my co-Chiefs and several senior attendings. The consensus was that, in many cases, readmissions will happen. This was obvious to me as a resident but now, as an attending (especially an attending on service for the first time), I felt I had done something wrong. The increased scrutiny, coupled with a heightened sense of self-reflection, led me to forget what I learned over my years of residency — sick patients tend to get readmitted.

The ideal teaching service affords everyone the opportunity to teach. At the helm of a large team (one resident, two interns, two students, and a pharmacist), I did my best to demonstrate ultrasound IVC measurements in a hypotensive patient with heart failure before giving fluids, pointing out Quincke’s sign in aortic regurgitation, and reviewing sodium homeostasis in a patient with hypernatremia. For the first few weeks I was so concerned about being a good teacher that I neglected to be a student. Our team had admitted a patient who was struggling to breath and with newly diagnosed interstitial lung disease when my student gave a brilliant, unprompted presentation on the etiologies of ILD on rounds. Only then did I remember that my students, interns, and residents all know things I don’t. Giving them the opportunity to teach me is vital and surely won’t be forgotten.

As a resident, I took pride in efficiency. Suspicious lung mass in a smoker’s chest x-ray? No problem — I could coordinate the CT scan, bronchoscopy, and pulmonary function tests the same day. My seniors hammered into me that disposition is the goal. The longer the work-up takes, the longer the patient stays in the hospital. When fixating on the total patient census, it’s easy to neglect practicing good internal medicine. As an attending, while I respect the differences between work-ups of inpatient and outpatient problems, I also realize it’s ok to adjust asthma medications, initiate treatment for GERD, or talk about depression in a patient awaiting placement for hip fracture.

Attending on the general medicine wards has been one of the most rewarding, fun, and challenging experiences of my short academic medical career. I’ve learned too many lessons to enumerate, but perhaps the most important of all is to not lose focus on the foundation I built during residency.

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