From residency to leadership: the evolution of internal medicine [PODCAST]

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Join us in this episode as we sit down with Janet A. Jokela, an internal medicine and infectious disease physician. Janet reflects on her transformative residency at Boston City Hospital, where the “city savages” thrived in the face of immense challenges. We discuss how the intense training shaped her career, the evolution of internal medicine, and the enduring commitment to compassionate patient care.

Janet A. Jokela, MD, MPH, ACP’s Treasurer 2022-2025, served as the Regional Dean of the University of Illinois College of Medicine-Urbana, and currently serves as Professor and Senior Associate Dean of Engagement at the Carle Illinois College of Medicine, Urbana, IL.

She discusses the KevinMD article, “Internal medicine physicians: leaders and the foundation of comprehensive health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today, we welcome back Janet Jokela. She’s an internal medicine and infectious disease physician. She’s the treasurer of the American College of Physicians. Today’s KevinMD article is “Internal medicine physicians: leaders and the foundation of comprehensive health care.” Janet, welcome back to the show.

Janet A. Jokela: Thank you so much, Kevin. Delighted to be here.

Kevin Pho: Always wonderful to hear your perspective and wisdom. Tell us what your latest article’s about and the events that led you to write it in the first place.

Janet A. Jokela: Thank you so much. I’m just so pleased to be able to share my story with you and others. Here’s the thing: Later in October, it’s Internal Medicine Day. And I started thinking about, what does that mean? Where did I really learn what it meant to be an internal medicine physician and how to do that? And it brought me back to residency. So this article is a little bit of reminiscing and just brought back a whole bunch of fond memories.

Kevin Pho: And in this article, you talk about your time at Boston City Hospital. And I think we talked offline, and some of my listeners know I went to medical school and residency at Boston University. I did my residency at Boston Medical Center, which used to be the Boston City Hospital. And I have fond memories myself of my own residency days. So for those of you who get a chance to read your article, tell us about some of those memories.

Janet A. Jokela: So I started to think about, well, where did I become a physician? And where did I learn what it meant to be a physician? And I realized it was all in residency. So, at any rate, long story short, I was coming from the Midwest. I was interviewing for residencies in the Boston area. And I remember I went to a prestigious Boston hospital, and it was all very impressive, very nice.

I remember asking the chief resident on that tour a few questions, including a quiet one, saying, “Well, what do you think about Boston City Hospital?” And he immediately responded, saying, “Those residents are angels. I don’t know how they do what they do, but they are amazing.” And unbeknownst to him, he sold me on the program, not on his program, but on Boston City.

Kevin Pho: So for those who aren’t familiar where Boston City Hospital, or now called Boston Medical Center, is, just give us a sense of the neighborhood that it’s in, the patient population that it serves, and what makes that place so special.

Janet A. Jokela: Delighted to do that. I tell you, I have such fondness for Boston City, it’s not funny. At any rate, it’s in the South End in Boston. It’s in the city. You drive along Mass Ave, going towards the ocean and going towards, what is it, I-93? I say I-93. And so you go in that direction, and there it was.

And it serves the underserved in the city of Boston. So people without insurance, people who don’t speak English, people who may be employed but don’t have insurance, but they are underinsured. And so it’s all walks of life, all walks of life. And it was really a pleasure to be there, a pleasure to be there and a pleasure to serve.

It was a hard place to work. People came in with ravages of alcohol use disorder, substance use disorder, hepatitis. At that time, we called it non-A, non-B hepatitis. That dates me. That’s OK. And we dealt with all of that. So it was a challenging place to work, but incredibly fulfilling at the same time.

Kevin Pho: So you came looking for a residency. You graduated medical school, didn’t have a lot of clinical experience. So tell us about some of the stories that really turned you into the internal medicine physician that you are today, stories that you learned from Boston City Hospital.

Janet A. Jokela: Oh gosh, how much time do we have, Kevin? We could chat for hours. And I do share a number of these stories with our current students today as they’re thinking about what direction to go in with their careers.

At any rate, one particularly fond memory that inspired me was, and I believe at the time I was an intern, one of the second-year residents. His job was to work and supervise in the ICU overnight as a second-year resident. He was all by himself. There was no attending in the hospital at that time supervising. But the lab, the entire lab in the hospital, went down.

And he had a patient in the ICU. I think it was with renal failure, and sure what else, but the patient had hyperkalemia. And he thought to follow the patient’s EKG and the T waves. And that’s how he monitored the effectiveness of his treatment. And it’s like, my goodness. We heard it on morning report the next morning, and we were like, “Oh wow. We are just so impressed and so proud that you thought to do that.”

But we will go to any lengths to deliver the best possible care that we could to our patients because they deserved it, no matter where they came from or what was going on.

Kevin Pho: In the piece, you coined a nickname, “city savages.” Tell us more about that nickname.

Janet A. Jokela: Our residency program director said, “You guys are city savages.” And we thought, “What are you talking about? What do you mean?” And here’s the thing: He reminded us repeatedly, and I came to experience it, that by the time you’re a third-year resident, we can take care of any challenge that comes in the door.

We were running codes throughout the entire hospital. The medicine resident, surgery resident, the consult service, we would go to all the codes. We would take care of the radio in the emergency room. So all the EMTs coming into the emergency room, we would be providing instructions and all of that to them over the radio. We took care of everything.

But we were really in the depths of all these details of all these really sick patients and complicated patients. We could take care of anything, and we were proud of it. And our residency program director was also really proud of that. And that’s where the whole nickname “city savages” came from.

Kevin Pho: Now you’ve seen the evolution of residency programs, and I’m sure a lot has changed since your time in residency. Now there are more structured schedules, there’s closer supervision, there are work-hour restrictions. So talk about some of that evolution in residency compared to what you were experiencing at Boston City Hospital.

Janet A. Jokela: We were incredibly proud as residents with all that we could do. And that said, in hindsight, we were relatively unsupervised. And in the big picture, that’s probably not, I shouldn’t say probably, it’s not optimal for the top-notch patient care that we so much want to deliver.

So today, with those changes and some of these things that you mentioned, including the advent of hospitalists and also electronic medical records, so many of those changes and improvements were really designed to improve patient care. I think that’s true. I mean, I think that’s all happened. And those are all important changes and important evolutions of medicine.

So these old days, we’re fond of all this and proud of the training we received. At the same time, patient care has improved over the ensuing years, and that’s a really wonderful thing, too.

Kevin Pho: So I want to talk about the influence your residency experience has outside of clinical medicine. Let’s say when you’re teaching fellows and residents and medical students, how does your training at Boston City Hospital influence your teaching style today?

Janet A. Jokela: Oh, Kevin, again, stories. Whether it’s teaching or relationships with others, it’s all about stories and sharing our stories. And I’m sure you recognize that probably better than a whole lot of people.

That said, working with students and residents, I do try to share stories as much as I can about perhaps the instance I told you about, the resident following the patient’s EKG, or other instances where we’re trying to kind of instill in students the same commitment, the same compassion, the same devotion to patients, and patients from all walks of life who deserve and who warrant the same level of really excellent care that anybody does.

So it’s those kinds of points, those kinds of issues that we try to share with students and residents to kind of ensure that we’re all on the same page going forward and really delivering excellent patient care.

Kevin Pho: So you mentioned back then that a lot of your clinical training, or some of your clinical training, was relatively unsupervised. But on the flip side, that gave you a lot of independence as a resident. So did that independence that you experienced during residency contribute to you now as a physician leader?

Janet A. Jokela: It’s an interesting question, and it’s an interesting point. Sure. So in retrospect, it may seem like we were unsupervised as residents of Boston City. At the same time, I think the teaching was so excellent and the clinical teaching was so good that if any of our attendings ever thought that we were a risk to patients, we wouldn’t have been permitted to do what we did.

And I do want to mention the nurses as well. The nurses watched us all like a hawk. So certainly, if we were to screw up or cause problems or anything, the nurses would let us know, but they would also be in touch with the attending. So while it may seem that we were unsupervised, in many ways there was a structure around us. Today, things are much more structured than what they were, and that’s good.

So in terms of today, working with students and residents, I do try to give our learners space, space to articulate what they want to do and why they want to do it, and then gently correct or guide as need be. So that independence is important today. It’s just more structured, and that’s OK. I mean, I think that’s a good thing, and it’s needed. So that’s all a good thing.

Kevin Pho: Now, historically, internal medicine physicians are detectives. We’re problem solvers. And you told that story about that resident who solved that problem when he was overnight in the intensive care unit. Now, with a lot of the administrative burdens and prior authorizations and just a lot of the obstacles that prevent physicians from having that time and space to solve problems, do you see that role as a problem solver, do you see internal medicine physicians’ role as detectives, is that changing today compared to back then?

Janet A. Jokela: Great question. I don’t think it’s changing. I mean, I think in people’s hearts, in people’s souls, this is what we do. This is who we are. We take care of complex patients longitudinally, over a long period of time. We solve problems. We’re disease detectives. We are expert diagnosticians, and that doesn’t change.

There are, as you state, these other external pressures which make things more complicated, make it more complicated to be. And I think that gets back to some of the, whatever you want to call it, moral injury perhaps, and the tensions that we feel between knowing what we need to do and also our time being squeezed in these other directions. So I don’t think it inherently changes what we want to do or who we are. It’s just more challenging perhaps today than it used to be.

Kevin Pho: So how can we overcome those challenges? How can we continue to be problem solvers despite those challenges that you said prevent us from doing so? How do you do it?

Janet A. Jokela: I’m so glad you asked that question. And one of the most important ways, I think, is advocacy. And the American College of Physicians in particular has a really strong advocacy team. And there are so many physicians and leaders within the college who participate in that. We have an annual Leadership Day where we talk about all these issues in Washington, D.C., with our congressional leaders.

But even beyond that, there’s so much work that the ACP is doing with prior authorizations and physician payment reform and all those kinds of things, many ways that are all geared towards protecting the internal medicine profession. It’s the profession that we’re trying to protect and grow and strengthen, with the end result being to take better care of patients. That’s why we’re here, and that’s what we do.

Kevin Pho: So if you were to repeat your medical career all over again, now that you’ve had time to reflect on it, would you do internal medicine again? And if so, tell us the reasons why you would choose internal medicine again.

Janet A. Jokela: And the answer is yes, absolutely. Absolutely would do it. I would do it again at Boston City, and, well, the Boston City that was, of course. I loved it, absolutely loved it. I so love taking care of patients and taking care of patients longitudinally and getting to know them over time, getting to know what their concerns, their issues are, and their families, all of that. I absolutely would have done it.

The diagnostic challenges are exciting. You’re always learning something. You’re always growing. And to be able to take care of these complex patients and follow them longitudinally is a real privilege. And there’s so much you can do. As my article talked about, internal medicine physicians are leaders. They lead within their clinical settings, within health care, in medical schools, all over. And it’s just a wonderful opportunity to put those skills to good use.

Kevin Pho: Now, for those medical students who may be listening to us on this podcast, and I know the ACP distributes this podcast to potential members and their members themselves, what kind of questions should medical students ask themselves to decide whether internal medicine is the right career path for them?

Janet A. Jokela: Gosh, that’s a really important question. And there’s a couple of thoughts I have about that. One is, I think the first thing students need to start thinking about: Do they want to do procedures or not? And then that may help divide them, at least in their thinking. Are they going to go a surgical route or more of a nonsurgical route?

Now, that said, there are opportunities within internal medicine, as we all know, to do many procedures, whether it’s in GI or pulmonary, cardiology. There’s a number of procedures that may be done in that way. But I think the procedure-and-not decision is a good place to start.

And beyond that, some of the things that we were talking about, to be able to really focus on diagnostics and being an expert diagnostician, and to also take care of patients over the long term and complex patients, and really be in a position where we can see the big picture and help take care of patients either one on one in the exam room or more broadly in a system, in a clinic or a hospital system. And it can be just so incredibly rewarding.

Kevin Pho: We’re talking to Janet Jokela. She’s an internal medicine physician and infectious disease physician, as well as treasurer of the American College of Physicians. Today’s KevinMD article is “Internal medicine physicians: leaders and the foundation of comprehensive health care.” Janet, as always, let’s end with our take-home messages to the KevinMD audience.

Janet A. Jokela: Thank you so much, Kevin. The future is in good hands. I tell you, the medical students that I see here at the Carle Illinois College of Medicine, and also medical students around the country, they are deeply compassionate. They are deeply committed to taking excellent care of patients. And they’re also deeply committed to medicine for the better. And I tell you, what more could we ask for? Our country, medicine is in very good hands. And I’m just so proud and so grateful.

Kevin Pho: Janet, as always, thank you so much for coming back on the show and sharing your wisdom, insight, and perspective.

Janet A. Jokela: Thank you so much, Kevin. Delighted to be here. Good to see you.

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