As a graduating senior resident I’m scared to practice outpatient medicine. In a community of patients and physicians crying out for primary care doctors, what are we doing at a training level to foster and promote confidence and independence at doing this?
Many bright eyed freshly graduated medical school students enter residency understanding the need and embodying the hope of pursing outpatient clinical practice. However, come residency graduation day, many of these once inspired budding outpatient physicians have turned into specialist practioneers or one of the many new breaded hospitalist physicians — lured by the 7 on 7 off model.
Something had to have happened in their three years of medical educational training that sent them off this primary care course. In my opinion, it is the incredibly flawed way programs go about presenting outpatient practice to impressionable new physicians.
Residency generally presents outpatient clinical medicine through a distorted pane of the mostly uninsured or state funded, lower educated population that make up the most difficult, medically complicated, noncompliant patients that can be seen in a clinical practice. These patients generally have at least 4 chronic medical problems with either an inability to obtain the medications needed or present with a demeanor that is unenthusiastic about their own health care. This can be exhausting to a new physician eager to find meaning behind the vague array of physical complaints and abnormal bloodwork.
Even for those patients motivated for improved heath, what is a diagnosis without an ability to financially support treatment? As residents many of us work in the dark ages with no ability to communicate with drug representatives or have any kind of exposure to newer agents on the market that when moving to clinical practice will be an expected component of our knowledge bank. Simple inhalers are unapproachable for patients and newer agents are just something we see on television.
In an environment still ultimately worried about the bottom line, residency clinic leads to a burden on residents by increasing patient numbers to account for no shows and forgiving late arrivals leaving you sometimes four patients behind. This moves the pendulum from education to service and resident mindset from one of heartfelt compassion for patients to disheartened clinic note machines. Residents typically see a panel of patients whom they are unfamiliar or have not seen in months which leads to overwhelming chart reviews, little time for discussion with attendings and reduced enthusiasm for medicine.
The way it is framed now, “continuity clinic” is a stretch in terms of building a true patient to physician relationship and establishing accountability for a patient’s health care. Many times lab are ordered and initially addressed before care is handed off to the next provider on a rotation with less demanding expectations outside of their clinical obligations who may or may not share your same enthusiasm for obtaining a diagnosis. Many times gallant patient workups are lost or repeated and halted at the same step as they had before. In this environment I question whether one truly can learn how to work up something as simple as hypercalcemia from start to finish in the mist of all the patient and system based barriers.
As the ACGME’s rules stand, continuity is defined as no resident going a month without a clinic which leads to one afternoon sprinkled in among hospital wards or other obligations. Is this truly what defines continuity? Is this truly what can be done to mirror outpatient clinical practice? This model leaves many residents with a sense of failure and defeat. A friend told me, “It’s a rare day I don’t leave clinic thinking I’m a horrible doctor. I don’t feel that way anywhere else.”
However, from the inpatient side of medical training a sense of accomplishment is possible. The treatments and medications needed to improve disease are at your disposal and patient compliance is contained within this controlled environment even for these more complicated patients. Sure a bounce back due to social barriers is hard, but people get better and people go home and you feel a part of that and its elating for a new doctor.
I’m scared to death to practice outpatient medicine. I don’t feel prepared and don’t feel successful in that world. Who wants to pursue a career bought up in a sense of failure? Despite training at a community medicine outpatient minded program, I still feel more comfortable and successful in the inpatient setting. There has to be a better way to present clinic medicine to young doctors or there is no hope to reducing the primary care void using new physicians.
Rebecca Crow is an internal medicine resident.
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