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. 

"Real-World" Medicine: 3 Things I Wish I Had Known as a Resident

4/16/2015 2:23:40 PM | 4 comments

When I was a resident, chest pain was all about the story.
During one history, I learned that my elderly patient was a ballroom dancer. "How long did you dance for?" I remember asking. "Was it a vigorous type of ballroom dancing?"
Today, I look back on those encounters with a certain nostalgia. Back then, the clock never seemed to be ticking. I had time to weigh the evidence and consider "zebras" (unusual diagnoses). Best of all, I really got to know my patients and hear their stories.
Sometimes during case discussions, an attending physician would describe "what we’d do in the real world." This always confused me. As the last stop in our training, shouldn't residency be as close to real-world practice as possible?

New Survival Skills

Fast-forward one year. I've completed residency and work as an attending physician at a busy, high-acuity community hospital. The transition has been exciting and rewarding. It has also required a huge paradigm shift in my thinking.
While residency was great for developing my clinical skills and judgment, it definitely didn't prepare me to deal with the Affordable Care Act (ACA) and other administrative realities impacting the practice of medicine. And because I no longer have the luxury of spending lots of time with each patient, I've had to find new ways to connect and care.
As a new attending physician, here are three major aspects of "real-world" practice that caught me off guard:
1. The pace ramps up. In the clinical setting, physicians, PAs and NPs are expected to see a certain number of patients per hour in order to meet their productivity goals. What's more, patients expect to move through the system with a certain speed and efficiency.
These days, I have about two to four minutes to perform an H&P before moving on to the next patient in need. I can't imagine taking a dancing history (or how hard my colleagues would laugh if I tried).
This ramped-up pace has changed many aspects of my practice. As a resident, I occasionally sent elderly chest pain patients home. These days, I'm much more likely to admit them for testing. In this setting, it's the safest thing to do. Older people are at significant risk for coronary artery disease and rapid deterioration. And unfortunately, I just don't have the time I had in residency to take detailed-enough histories and sort out who might be an exception to the rule.
There are other changes. In the name of expediency, I order more tests. I spend less time trying to turn patients around before deciding to admit them. And while I do my best to steer patients away from unnecessary care, I've learned to choose my battles when they insist on a particular test or procedure.
Pace also impacts the provider-patient relationship. My patients today are often less vivid and memorable to me than those I saw during residency. That being said, I've learned that I don't need to know everything about someone to show I care. Honesty, reassurance and empathy can be far more powerful than prompting an unwell patient through six decades of life history.
2. There’s a difference between knowing medicine and knowing how to take good care of people. A primary function of a teaching hospital is (naturally) to advance medical knowledge. As a resident, I focused on learning medicine. When someone had an interesting case, I dropped what I was doing and went to check it out. I never worried much about throughput metrics or peeked into the waiting room to see what was going on.
Real world practice, on the other hand, requires the mastery of a whole new set of survival skills. I now fully appreciate how difficult it is to move a patient through the process of care. I've also gained new respect for all the work that goes into improving and monitoring the quality of our care.
These skills aren't emphasized in residency, but under value-based purchasing, they still have quite a huge impact on the patient, provider and hospital. A hospitalist or ED program that struggles with throughput will impact hospital’s bottom line, Such programs risk losing their contracts.
More importantly, patient flow has a direct impact on clinical outcomes. For example, patients in crowded EDs are more likely to die, have longer inpatient lengths of stay and experience potentially dangerous delays in care.
The good news is that what’s best for patients is usually what’s best for business. Patients, providers and hospitals all want the same things: positive outcomes and great service at a reasonable price. So when we focus on doing our best for patients, the administrative details tend to fall into place.
3. Trust is earned. In my first job as an attending physician, I'm lucky to be teamed up with some very seasoned providers. There are nurses in my department who have been working in the ED for as long as I’ve been alive. On busy shifts, they’re a tremendous help, whether filling in a piece of missing history or pointing out a patient who needs extra attention.
While we're a very collegial group, it still takes time for newcomers to earn the group's trust. Completing your training as a provider or RN doesn't mean your teammates will have unquestioning faith in your judgement. And unfortunately, conflicts are most likely to arise during difficult, emotionally charged situations.
I recently spent over three hours working on a 10-year-old boy who came to the ED in the throes of a severe asthma attack. None of the usual treatments — magnesium, steroids, epinephrine, terbutaline — were helping, and he was in danger of crashing.
"Why aren’t you putting in an airway?" one of the more experienced nurses asked.
I explained (as thoroughly as possible under the circumstances) why in children with an acute asthma exacerbation, placing an airway is a last resort.
The nurse wasn’t buying it. "Why did you start a ketamine drip? We can’t sedate someone in respiratory distress”
In moments like these, it's important not to take the doubts of others personally, and also to realize they are only looking out for what’s in the patient’s best interest. Earning trust is a human process, and it takes time. Remember too that speaking up about doubts is a positive thing. Having a culture of openness makes our patients safer.
At the same time, it's important to have confidence in your training. Working in the ED doesn't imbue a non-physician with a nuanced understanding of the disease process, just as it doesn't make me an expert in nursing theory. As an attending physician, I'm responsible for the patient's outcome. I can listen to the counsel of others, but ultimately I need to trust my own training and judgment.

Parting Thoughts

Sometimes I wonder what the attendings who taught me would say about the way I practice today. Then again, the teaching setting necessarily operates differently. Healthcare professionals need sheltered time to work through complex cases and hone their clinical judgment before they start worrying about productivity and HCAHPS scores.
I also try to remember that academic and community hospitals are structured quite differently. At the former, residents provide a lot of extra manpower that frees up time for teaching and learning. And the attending physicians are hospital/university employees, not contractors who are contractually obligated to deliver certain outcomes and metrics.
While adapting to the "real world" of medicine has been a long road at times, it's also been exciting. By attending to the business side of our profession, we enable our hospital to fulfill its mission of serving the community. And while the mandates of the ACA sometimes feel onerous, it's also amazing to see how many patients we can serve when providers and hospitals align their efforts toward common goals.

[Image credit: "Taking care of the young" by selmaemiliano licensed under CC BY-ND 2.0]

Dave Birdsall
Great article Allen. You made me nostalgic for residency.
6/26/2015 6:31:34 PM

Seth Thomas
Couldn't have been put any better. An accurate and sobering description of the post-residency learning curve. Well done Allen!
6/22/2015 9:48:27 PM

Kevin Riggs
Thanks for your perspective! There is a steep learning curve when transitioning from the academic to the real world practice of medicine. Trust in your training and continually utilize your more seasoned support staff to ensure your success as a clinician. After 12 years, I am still learning!
4/27/2015 9:24:44 AM

Cyndy Flores
Thanks for sharing your thoughts. Entering emergency medicine these days is so different from when many of us started and so you get a big high five from me!
4/17/2015 2:37:21 PM