Thursday, June 16, 2005

Upcoming Tour of Duty on the Teaching Wards

I'm going to be very busy for the next two weeks starting today. I'll be attending on the wards with the housestaff at our institution (Harbor-UCLA Medical Center). We generally do three to four of these two week rotations a year. It's a great opportunity to work with the residents and interns in a very intense, very personal environment.

Our patients are generally very sick, very poor and often very complex. There's a lot to see, to do and to teach. And as attendings, we maintain a very visible presence.

It wasn't always this way. When I was a house officer, we rarely saw our attendings on the wards. They were only peripherally involved in the cases and we perhaps rounded three or four times a week in the morning and never saw them the rest of the day. It was exceedingly rare to see our attendings on weekends or holidays and except for one crazy (but wonderful) attending I never saw one at night.

Now, attendings are much more visible and involved in patient care when rotating through the wards. There are several reasons for this the most important of which is that residency programs are under much more scrutiny than in the past. The Accreditation Council for Graduate Medical Education (ACGME) is very active in insuring that basic minimum standards are maintained. This applies to both patient care and to medical education. Programs have to be concerning with maintaining a good balance between the two. They have to be in strict adherence to ACGME guidelines or they risk losing their accreditation.

The ACGME has mandated much greater involvement of attendings than has been the case in the past. For me, that means a lot more rounding, a lot more contact with the house officers, a lot more "laying on of the hands" and a lot more teaching.

This is good. As attendings we are the physicians of record and as such are responsible for the patients' outcomes. Certainly this degree of involvement is good for patient care (to the extent that attendings do more good than harm). The greater opportunity for housestaff to see how we function in the day-to-day management of sick people is also a good thing.

Sometimes however, I wonder how residents feel about this. They have lost a little bit of autonomy compared to what we had as residents. It is certainly incumbent upon us to step back and increase their level of responsibility particularly now since the end of the year is upon us (housestaff work on a July through July "fiscal" year). Our interns (R1's) are pretty much functioning like 2nd year residents (R2's) at this point and our 2nd years are ready to take on the greater responsibilities of senior residents (R3's).

Doing the last two weeks of June is a particularly interesting time. The interns switch on June 23 (their cycle is staggered by one week from the R2's and R3's). I will therefore have the opportunity of working with a seasoned group of battle-weary R1's during the last week of a very long, very stressful internship. I will then have the hopelessly green, brand new interns fresh out of medical school for their first week. I worked the same rotation last year.

Talk about contrast!

Well, I've rambled enough. Bottom line...there won't be a lot of time for blogging although I hope not to be silent. Try not to forget me!


Blogger Fred Mangels said...

Won't forget you. Have your blog bookmarked and check it every day.

June 16, 2005 7:06 AM  
Blogger james gaulte said...

I have your blog entered on so I'll know when you update. I'll be interested in any posts about the rotation as I may be taking on some teaching in an outpatient setting for IM residents in Jan.06. Maybe by that time I'll figure out what exactly what all is intended by some of the ACGME competencies. Good luck.

June 16, 2005 9:50 AM  
Anonymous Anonymous said...

It's good to have an attending who gives so much thought about the interns... Unfortunately, most interns don't feel their work appreciated and a little bit of attention and encouragement can go a long way. I always try to remember that we all were interns once.

The upcoming class might find helpful tips in some of the articles on our residents' website:

-ICU/Floor What To Do Guide

and especially, the procedure guides like:

-Central Line Placement - Procedure Guide - with a step-by-step slide show

If they feel like starting a blog to collect useful resources, I will be glad to help (or they can just borrow from our links)

June 16, 2005 9:56 AM  
Blogger The Medicine Man said...

Thanks for the thoughts Fred, James and Clinical! I appreciate the comments.

So James, you're thinking of doing some ambulatory medicine teaching? Trust me, it's a great experience and a great opportunity to put back some of what you've taken from your career in medicine.

I was a volunteer attending for years before I took a full-time job at UCLA. Your residents will really appreciate the input from a physician who's really worked in the trenches. Sometimes they just need to hear the "nuts and bolts" of medicine.


I am very impressed by your blog although it is rather difficult to navigate through (something some of our residents have told me since I turned them on to your site). I'm going to see if I can some housestaff interested in setting up a similar blogsite here at Harbor-UCLA.


June 16, 2005 3:43 PM  
Anonymous Anonymous said...

Dr. Gaulte teaching? that'd be neat!

June 18, 2005 10:52 PM  
Anonymous Anonymous said...

I work at a teaching hosptial, and i love watching the student doctors follow there teacher around. It reminds me ducks following each other, all in a straight line, so serious. We got some good Docs. I think they enjoy giving them a hard time.

June 19, 2005 6:31 AM  
Blogger Fred Mangels said...

That two weeks must have stretched into a month.

July 15, 2005 6:37 AM  
Blogger Henry Stern, LUTCF, CBC said...


Yeah, but you know how those doc's are: "Oh, the doctor will be with you in a minute" (while you're sitting in the exam room freezing your blogs off because they've had you undress while you're waiting).


I miss my Dr John fix, too.

Just sent him an email about some new developments re: The Groningen Protocol, maybe that will get him fired up.

July 16, 2005 9:56 AM  
Blogger Fred Mangels said...

I guess it didn't work, hgstern. I wonder if something bad happened to the doc? It's been a month and a half since his last post.

August 02, 2005 6:45 AM  
Blogger Henry Stern, LUTCF, CBC said...

Hi, Fred!

I'd hate to think that anything untoward has befallen the doc; more likely, he's taken a break from blogging for a while.

Still, it seems odd that he'd skip replying to email altogether.

I wrote to him several weeks ago, and haven't heard back yet, which is unusual.

Miss his posts, tho...

August 02, 2005 6:17 PM  

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