Back when I was a resident…

Robert Chang writes…

Past distinctions
The phrase evokes different emotions from people, mainly memories of long boring stories that seem unrelated to the way things are now.  Despite a promise to myself, I actually caught myself saying it the other day listening to a story about some triage mishap for a patient.  But I realized that underneath the long boring story I was about to tell was history, that things change and on top of that, the contrast can help us understand the now.  I’ve been at the same academic institution since I started medical school so I have a history here at Michigan.  I’ve watched how things developed, why things changed and have been a part of the culture of this place – “this is how we do it here”. 

And back when I was a resident, it was clear who was an attending and who was not.  The attending-resident relationship was generally vertical, although far less explicitly than implicitly.  The attending and resident discussed patients and crafted a plan but ultimately, residents did what attendings wanted, due to components of hierarchy, seniority/experience, legality and other issues.  The attending went off and did other things while residents made the plan happen, no matter how long that took, wherever you were in the call cycle.  That changed some with the work hour restrictions but the majority of the direct work still falls on the residents.

Academic Hospitalists through the glasses of a resident – in brief
With academic hospitalists on non-resident services, the distinction between resident and attending is less clear.  Work isn’t divided along certain lines – the title of attending no longer comes with freedom from some tasks (have you put in that NG tube yet?  We need to pass meds).    That blurring of roles comes with the attendant understanding that the work done while a resident will remain part of the work as an attending – sustainability and desirability are serious questions.  Lastly, the peculiar nature of academic medicine, where time is often valued more than money and patient care is not necessarily seen as business and profit but rather time consumption, and the fellow/resident-driven consult services, who have little direct incentive to see patients, blend to create an environment where the normal collegiality that can hold community hospitals together is strikingly absent (I don’t think we need to see that patient but we will if you insist on it).

Changing perceptions
So where does that leave things?  If the work that previously distinguished a resident and attending is no longer clear, then what really distinguishes a hospitalist from a resident aside from experience (if any, as a fourth-year med/peds resident has as much experience than a new hospitalist)?  Ultimately, salary delineates between the two unless steps are taken to make the differences clear.  My last blog outlined some of the pieces of the hospitalist world and making the resident-hospitalist piece healthy relies on several things:

Things to keep in mind:
a. Take the long view and the high road.
b. Small things affect people greatly.
c. A generation of internal medicine residents passes in 3 years, and every year marks another generation who we can show the strange beauty and value that comes from bringing all the disjointed resources that a hospital has to bear to help people that come to us.

1.  Change their glasses
Invest in growing the future perception of our field – our interactions with residents, whether on consult teams, attending on the wards, or interacting regarding the triage of patients, will define the perception of what the next generation of residents see hospitalists.  More than any other attending, we can leave our mark on how residents will come to view and understand our field due to how closely we interact with them.  Our daily interactions matter.

2.  Shape and define what it means to be an attending in your hospital.
The days of “do it because I said it” are numbered except in the most hierarchical of programs.  Take it a step further and return the mentor-student relationship to residency.  The surprising freedom that came when I first graduated – “You’re an attending now!  You can call the consult attending if you aren’t getting an answer from the resident” “Call me by my first name” – shouldn’t have been so surprising.  The abrupt and jarring “switch-effect” of becoming an attending should actually be an experience of collegiality that is expected and comfortable.  We’re growing residents to become physicians, not just teaching them medical information.

3. In addition to daily interactions, seek ways to enter their world.
Some things our group has done includes:
a. Staffing morning/intern report
b. Create a group that meets with residents and the chief residents to mediate and discuss issues between groups.  Use the time to find mutual areas where both sides could benefit (problems with getting an MRI, engaging the ED to cooperate in patient admissions etc)
c. Invite residents to participate in quality improvement projects
d. Engage around codes (if your group participates) and perhaps seek to develop group training

The last comment I wanted to make: this is one of the key steps to building our general success in the academic world.  We need sharp and committed physicians who will ultimately provide excellent clinical care and commit themselves to research.  What is right is often also healthy, and in this case, the healthy growth of our field is paired inextricably with shaping young men and women into excellent and caring physicians.

2 Comments

  1. Jairy Hunter on April 2, 2009 at 9:21 pm

    It’s very difficult to assume the role of The Professional…to exude that confidence and (gravitas?) that one is expected to possess the day we finish residency. I suppose that’s why we adopt mentors and others we try to emulate. Physicians are always among the “most respected” professions, whatever that means, and people expect (and, I guess, deserve) a certain level of comportment. I’ve never been comfortable seeing friends, former bosses, or teachers (even my high school principal!) as patients, but on the other hand I guess I’m gratified that they would trust me enough.

    It’s also funny how that wall seems to come down a bit once you leave “campus” so to speak, and now that we’re in the Club, we’re treated differently by other physicians.

    I had an experience a couple of years out of residency, when I was practicing outpatient family medicine that opened my eyes to the changing world of even academic medicine. My nurse pulled me out of a room to answer another physician’s phone call, presumably about a patient.
    It went like this:
    “Jairy this is Fred.”
    “Fred….?” (as if I’m supposed to know).
    “Crawford.”
    It was the Chief of Cardiothoracic Surgery from my medical school about 5 years before, the mere mention of whose name struck fear into the hearts of legions of residents, not to mention medical students. I’m not sure any medical students ever even saw him, much less talked to him. Needless to say, he was quite polite and gave me what I’m sure was an excellent update on a patient we shared. But I’m sure I didn’t hear a word. He understood the importance of establishing and cultivating the primary care relationships in the changing economic climate of academic medicine as competitor hospitals were fighting for the slightest edge even 10 years ago.
    My nurse came to get me as I stood for several moments after hanging up, my mouth agape…
    “Who was that?” she asked, incredulous. “You look like you’ve seen a ghost.”
    “I just had a real live conversation with…,” then I thought for a second. I felt so so silly, to have been awestruck by another doctor.
    “Nevermind. You wouldn’t understand.”

  2. Robert Chang on April 3, 2009 at 8:42 am

    Jairy,

    Thanks for sharing your story. It really marks that transitional moment of being on the outside looking in and having the door open. It is interesting that the way we lead our residents is this sudden opening of doors, this bright light that opens at the end of this long tunnel. I would say that it is rare that a new attending would feel completely confident in his clinical skills (and that confidence would like be misplaced), but the confidence that we can instill in residents in joining the Club is part of re-defining what an attending is. That redefinition is part of what will help residents view hospital medicine not as an extended residency, but a much more natural transition.

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