Every year, there’s this rite of passage, the passing of the baton, as our graduating senior residents move on to fellowships, or into spots as hospitalists, or to practice jobs here in New York City or other cities, and a fresh new group of newly-minted physicians arrives ready to take up the gauntlet of training as Internal Medicine doctors under our dysfunctional 21st-century health care system.
The parting departing senior residents have closed out their electronic health record (EHR) accounts and deactivated their hospital e-mail, emptied their mailboxes and turned in their pagers.
What, no pagers?
Turns out the new interns don’t even have pagers. How could this be? Getting a pager was that badge of honor: You’re the doctor, page me if this patient gets unstable or when the family arrives, or when Radiology is ready to go over the CT scan.
The new interns carry a second HIPAA-compliant cellphone that is programmed with special software and hospital-specific apps for communicating between members of the team. No more will that sound of a pager going off rouse the sleeping resident, jangling them back to consciousness. Mrs. Smith on 4 North in Room 454 is unresponsive/febrile/having chest pain? On my way.
As the departing senior residents left to go on to the next phase of their lives, their last days here were marked by joy and sadness, anxiety and excitement, fatigue, and passion. Multiple times, they have come into my office and expressed how much they’ve ended up enjoying the outpatient practice, the relationships they’ve forged with their longitudinal patients, and how saying goodbye to those patients has often brought tears to their eyes — their eyes, and their patients’.
Many of our patients have trained many generations of internal medicine residents, and we are honored that they’ve allowed our trainees to participate so intimately in their care. While outpatient medicine has not always been considered the sexiest of career paths — especially when the residents are exposed to being the overnight critical care consult resident on-call for the medical ICU — there’s a lot to love here.
Helping our patients get to a better state of health, to overcome barriers to equitable care, and adapting to the role of being a patient, is incredibly rewarding, no matter what kind of doctor you want to be when you grow up.
Unless you’re going to be a hospitalist or an intensivist, or work full-time in a research lab, most graduating residents will ultimately have some outpatient office practice where they see patients, be that in nephrology, cardiology, gastroenterology, endocrinology, infectious disease, or whatever they choose. The skills they learn here, seeing patients in an office setting, away from the hospital, will prove valuable to most of them, whether they realize it now or not.
The changing environment
As we look forward to the year ahead, we see these new interns entering an incredibly complex health care environment, where they are faced with endless challenges and frustrations. Remembering back to my own first days of internship, I remember we had a bunch of orientation sessions, including a mini-course on advanced cardiac life support followed by a certification test, and a session with the critical care unit nurses on how to scrub and put on sterile surgical gloves. They delighted in telling us that we were doing it wrong, that as we flipped the glove up and on that it touched our nose or our sleeve, and that we were surely going to contaminate every patient we tried to take care of that year.
But beyond all this, I mostly remember them saying, “Well, let’s get on with it then,” and we started working.
I started working on an inpatient medicine ward, receiving a list of over a dozen patients who had been there for some time, some of them quite sick, some of them already diagnosed, some of them still medical mysteries. My first admission as a medical intern was a patient with a necrotizing oozing neck mass, whom we ultimately diagnosed, after performing an acid-fast stain on the discharge, with scrofula. We felt like heroes.
This morning, our medical interns had their orientation session with us, after completing a week of requisite training, lectures, filling out forms, and more. Today, it started out with billing and compliance. Really? This is the priority in the lives of our trainees?
There is a large policies and procedure manual, which includes information about handling disruptive patients, filling out transportation forms, homecare forms, and many helpful tips on navigating the electronic health record.
But as we sat there, going over the billing and compliance rules, 99211 through 99215, and how to assign the appropriate ICD-10 codes, I grew more and more despondent. 10 plus Review of Systems items needed to get you to a complex billing level. How did we let the system erode so much that this is what was important for them to learn?
True, since then they’ve had lunch and are now setting off seeing their first patients of the day, of their residency, and there are 100 or so patients out there in the city who are empaneled to them, and I know they will learn to love being the primary care provider for these patients over the next 3 years. But what message does it send when we have to have a whole orientation module on how to fill out transportation forms, homecare forms, Medicaid threshold override application forms, and sessions on how to get patients the durable medical equipment (home oxygen, CPAP machines, walkers, hospital beds, incontinence supplies) they need?
Let’s demand better
To inspire the next generation of doctors to continue in this field we all love so much, to do this work we love, taking care of outpatients, we need to continue to demand that the system remove all of this baggage from the training of our interns and residents, as well as from our faculty, to allow us to thrive as caregivers, grow as learners, revel as teachers, and build the relationships that we need between our patients and our providers, and amongst our providers, to help revitalize our health care system. Seeing an inspiring model of care, finding a mentor, learning at the side of a master.
Somehow, by hook or by crook, we have got to find a way to get all of this extraneous work, things that don’t really require a medical license, done for our patients without us having to handwrite out another form and fax it over. Build me some information systems that can process this stuff automatically, bring in some virtual scribes, change the rules, devise a system of machine learning to find gaps in care, spread the work out so that it’s not all being done by those of us working hardest to take care of our patients.
Time to reorient our priorities, so we can work, care, learn, and thrive. Let’s get to work.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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