03 February 2010

Not dead yet

Been pretty quiet here lately.  I've been working clinically quite a lot, and have some cool things going on in my professional life that I just can't blog about -- more's the pity.  It's funny, with several years of blogging under my belt, when something interesting happens, my automatic instinct is to post about it.  I've just gotten used to living my life in a very public fashion.  But it's not a great way to run a business -- there are lots of things that simply have to be kept confidential.  So I compartmentalize it, but I still can't stop writing the hypothetical blog post in my mind and thinking how cool it would be.

Yeah, I'm a terrible tease.  Sorry.

I've got a few posts ready to come out over the next few days if I have time to put them in decent shape, but till then I'll content myself with linking to an interesting commentary via GruntDoc:

GruntDoc  We’re Failing Our Residents: Training ED Docs for the Real World
Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day.

Right on.  I used to joke, after doing a residency at Hopkins where there were no fewer than three separate ENT services on call every day, that it was a huge culture shock coming to a community hospital, even a relatively busy one.  When I was frustrated I would loudly exclaim "Whaddya mean there's no oculoplastics in-house on-call?" in a joking tone, or I would muse "So how long have you people had electricity anyways?"

But I think this article slightly misses the point.  After three years of critical care training and trauma care, after working with specialists shoulder-to-shoulder every day, that stuff is actually not too hard.  You do a few peritonsillar abscesses with the ENT resident, you do a million trauma resuscitations with the surgeons, and you can replicate their thinking and decision-making with reasonable quality.  When I got out of training I was pretty comfortable calling up a surgical consultant and telling them what needed to be done (or at least giving them enough information to formulate a plan). 

It was the little stuff, the low-acuity stuff that was the real head-scratcher.  I still remember the first time I saw hand-foot-mouth disease.  Kinda embarrassing, now, the work-up and effort I put into what is today a doorway diagnosis.  The mandibular dislocation.  The lacerations in odd places.  Foley catheter trouble-shooting.  The rashes.  The weepy umbilicus stump.  A lot of primary care-type issues.  All of this was stuff that I just had to figure out on my own, jury-rig it with duct tape and baling wire and hope to hell that I had gotten it right.  And now that I'm one of the more senior docs, I see my new graduate colleagues struggling with the same things.  Fortunately, I can be a resource to them and show them the tips and tricks that I discovered, just as my senior partners were for me.

I don't think I'd say we're failing our residents, though.  This stuff is not too hard to figure out, and the breadth of the problems that you will see in an ER is so huge that it's just not possible to see everything in a three-year residency, much of which is spent on off-service rotations.  It's certainly more important that our grads be able to do the critical care and procedures to a very high standard of quality from day one after graduation, and this in fact has been my experience.  The folks we have hired universally have been comfortable managing the really sick patients, and I think that's the important thing given the limitations of training and the need to prioritize topics.

The source article does make another criticism of ER residency training that I have been harping on for years:
 We're Failing Our Residents...
Residency programs train physicians in some of the most inefficient EDs in the land. Relative value units of emergency medicine work per hour in the teaching hospital setting is typically half that seen in private practice. And residents train in a culture where customer service is an unaffordable luxury amid the chaos of the typical academic ED. ... These safety net patients have nowhere else to go and so will tolerate greater waits and delays without leaving. On the other hand, community hospital patients are more likely to be adequately insured, and have higher service quality expectations. [...]

We continue to graduate physicians with no proper training in health care management and few of the leadership skills necessary for working in a health system that is increasingly organized around team care and team management. ... [T]he academic emergency medicine anti-business bias should be replaced with the realization that no emergency medicine practice can survive or prosper without sound business leadership and management skills. These abilities are not typically necessary in the world of academic emergency medicine, but they are imperative in the rest of the practice world.
This is a predictable consequence of the RRC core curriculum requirements and the incredible emphasis placed on the inservice exam scores.  The residency directors teach to the test.  Billing, management, healthcare economics, and ED operations are not on the test, so they're not in the curriculum that residents are exposed to.  It's a rational choice, if youa re a residency director. If you have an open lecture slot, you can have someone come talk about difficult toxicology cases or billing stuff, you for the tox, no question.  (Plus, many academic docs have never worked outside academics and so they have no experience in billing/management/ED operations, so they can't informally teach residents in the ER.)  The consequence is that ER docs graduate naive and vulnerable to exploitation by their employers, unprepared to succeed in their new job, and left to figure it out along the way or not.

To their credit, some residencies have recognized this deficiency and have made small steps to remedy it, but it's generally inadequate.  Still, credit where it's due.

It's also telling that this criticism of ER residency training, coauthored by several respected and accomplished leaders in the field, was published not in ACEP's Annals of Emergency Medicine, nor in Academic Emergency Medicine, but in the trade publication, Emergency Medicine News.  I have to wonder whether this was a deliberate choice on the part of the authors, or if the "respectable" journals shied away from such a topic.

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