Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Building Continuity in a Continuum

4/27/2013 12:01:10 AM | 0 comments

The term “hospitalist” was first mentioned in 1996 in an article in the New England Journal of Medicine. Although the field has come far since then, there are still no residencies offered for hospital medicine. Without a formal residency to train hospitalist candidates, administrators must decide whether to recruit recent graduates or experienced hospitalists to fill their needs for this rapidly growing specialty.  

Since there are no hospitalist residencies, most of our candidates apply to us after doing a traditional Internal Medicine (IM) residency. We are fortunate to have a plethora of qualified physicians applying for our positions and the majority of them tend to be recent graduates. Being in the San Francisco South Bay region helps us draw candidates, as does our affiliation with a major teaching center. In addition, having our own IM residency gives us a pool of applicants who are already familiar with our hospital. We tend to get more CVs than we have capacity for, which, as physician recruiting expert Barbara Katz points out, is not the norm right now across the country.

So what is my approach on how to train a recent graduate? First of all, I realize that it takes about a year for the new graduates to be comfortable in their new roles as hospitalists. In the first few months, we help them lose the "over the shoulder syndrome"—the habit of looking for the attending to sign off. It is important that they learn to take responsibility for both patient care and the operations of the hospital, and for this to happen they must feel empowered to think and act quickly.

When they start, we have a hands-on orientation. On the first day, we have them shadow one of the more experienced hospitalists to learn our technology system, and then, when they have mastered the basic computer applications, we have them see a patient. They gradually add more patients until, by the third day, they are seeing a full load of patients on their own. 

They are never alone during the training period and beyond. They work side by side with two or three experienced hospitalists so they can ask questions, get to know the consultants and case managers, and become familiar with all parts of the Acute Care Continuum. We teach them how to navigate the system, and this takes time since each system is unique unto itself. Of course, it does take extra work to train someone without experience. But I find this investment to be well worth it for their career satisfaction and our retention rate. 

As the medical director, I work as many shifts as our full time hospitalists, so I am on the floor to help train our new physicians. To evaluate their progress, I often take over their patients so I can see their H&P, progress notes and discharge summaries, and I ask for feedback about the trainees from the other hospitalists in my group. I use this information and my own observations to give lots of feedback to the new graduates. I watch them round, and if they seem to be overly stressed, I help them analyze what they are doing in order to find a better/easier way of doing things. I try to push the new graduates to think for themselves, but also to know their limits and ask for help when they need it. After six months, they should be getting more comfortable in their role, and if they are not, I sit down with them to figure out why. I believe that this proactive approach early on and then and on-going intervention creates better job satisfaction. 

Some doctors are meant to be hospitalists and some are not. Over the years, we have found that with careful screening we can find the right people for our program. We look for physicians with excellent qualifications who fit well into our group, who share our work ethic, are willing to be flexible and cover for each other, and who are eager to learn something new. As hospitalists, we often spend more time with our colleagues than we do at home, and building a cohesive team at work can be as determinant to our happiness as a happy marriage. Ninety percent of the physicians currently working in our group were hired as new graduates, and we have minimal turnover. That tells me that we are doing something right.



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