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!