July 10th, 2015
Transitions of Care
Brief HPI: 3rd year resident, Asian-American male, from Philly, presented to Emory University as a wide-eyed intern July 2012, currently admitted to become a new Chief resident at the VA
Meds: see EMR
Pertinent Labs: see EMR
Top Active Problems:
- Computer Codes – missing but awaiting IT approval
- Awaiting MRI of brain past 48 hrs – syncope work up
- Psychosocial – extremely anxious to start chief-ing and leave behind a transformative experience in residency
Sign-out: NTD overnight
Anticipatory Guidance: If starts to have a panic attack about being chief, ok to give Haldol 2 mg IM
Medical transitions of care are never easy – just the thought of signing out patients to a night float resident frightened me as an intern. Even as an upper-level resident, I was unsure at times of my ability to properly hand off patient care. The above example follows a standardized format to give a cross-cover provider a succinct overview of a patient’s care, but things do get lost in translation. There is no better example of this at my residency program then the ICU month at our public safety-net hospital, Grady. Below is a graphic of our ICU sign-out structure:
Our ICU signout process
This format keeps a team (1 resident, 2 interns) intact by avoiding any 24 hour calls; however it was extremely prone to sign-out mishaps and fragmented patient care. One case I will never forget ended up with a patient coding, likely due to hypoglycemia. During verbal sign-out rounds at 8pm, no one mentioned hypoglycemia; in fact, the call team (day team 1 in above graphic) did not even know much about the patient’s history or reason for ICU admission. The written sign-out also left out the critical information that patient had a blood glucose of ~25 on arrival to the ER. This was the infamous sign-out of a sign-out we all dread from multiple departments, let alone in the MICU.
While medicine transitions of care sometimes leaves a sour taste in my mouth (thankfully, iCompare, the flexible arm, will allow for a MICU 24-hour call system and hopefully address these sign-out issues), I want to now focus on a much different, non-medical transition – leaving residency.
As I signed out in the beginning, I’m going through the initial pangs of transitioning to my new role as a chief resident. It is a wonderful opportunity to teach, mentor, and work on the administrative side of academic medicine. But leaving behind the wonderful class of 52 residents I’ve worked with, laughed with, and cried with has made this transition so bittersweet.
Many in my class will move away from Atlanta, GA — in fact, will move to 13 other states by my count. The time I’ve spent the past 3 years with these individuals has been transformative, a thorough ‘through-the-fire’ refining. Residency launches many of us into a maelstrom of clinical duty mixed with scholarship and rounded out with lifelong bonds formed from shared experiences that only other co-residents can understand. My experience was so intricately tied with who I worked with that I know the friendships and memories made will endure much longer than my career. So if you’re a graduated resident, a graduating resident, or even a budding student doctor, remember to cherish the people you work with and the memories you make along the way.
One part of me is excited to transition to my new role as a chief resident, but the other part of me, ironically, doesn’t want to sign out of residency. Is that so wrong?
I would love to hear other people’s thoughts on transitions in their medical training, or even thoughts on transitions of care within the hospital!