Spotlight on Graduate Medical Education
There’s an old joke that gets passed around teaching hospitals: don’t get sick in July. Why? July 1 is when the new residents arrive on the floors of the hospital, fresh from medical school and with limited patient care experience under their belts.
Television medical dramas like to portray residents as bumbling indentured servants at the mercy of eye-rolling nurses and demanding attending physicians. While the role of the resident has evolved, they continue to walk a fine line between being a student and an employee, but the residents' primary purpose or reason for participating in the program is to further his/her education, skill, and ability in the practice of medicine. They provide a service to the hospital, and in return, receive an education from patients, faculty and staff. They dedicate most of their young adult lives to a rigorous training program, which lasts from three to seven years.
Somewhere along the way, they become the teachers, mentoring medical students and younger residents. The system of “see one, do one, teach one” has endured for 100 years, but Vanderbilt’s Office of Graduate Medical Education (GME), first under the direction of Fred Kirchner, M.D., who led it for 20 years, and now Donald Brady, M.D., MD ‘90, who succeeded him in 2008, has raised the standard and has implemented a number of innovative programs to support, nurture, educate and graduate the next generation of physicians.
Jokes about new residents aside, it is true they don’t know the vast majority of what they are expected to do their first day on the job. They arrive at Vanderbilt from numerous medical schools and with varied clinical experience.
“When I was an intern, I didn’t know how to do anything,” recalls fourth-year General Surgery resident, Kyla Terhune, M.D., who remembers being overwhelmed during her first rotation, which was in the Surgical Intensive Care Unit in 2004. “Although I love the ICU now, every time I walk into the ICU, I remember that gut-wrenching experience of walking in that first day.”
To help ease the transition from student to physician, Terhune, along with Arna Banerjee, M.D., assistant professor of Anesthesiology, conducts a two-day “boot camp” for incoming residents. Boot camp orients interns to the unstable patient (managing an airway, performing CPR); the stable patient who has medical issues (decreased urine output, change in mental status); and basic skills (placing chest tubes, obtaining vascular access, knot tying for Surgery residents).
“Residency relies on a system of sequential teaching: attending physicians teaching senior residents who teach junior residents. Boot camp just adds a little more structure to the system,” Terhune said. “I felt like there were certain skills I’d rather not use for the first time on a patient. Every experience during internship is a new experience. You can’t predict what all the new experiences will be, but you can try to figure out the most important ones and address those.”
The Department of Emergency Medicine offers a month-long didactic orientation for its 12 first-year residents. Before they treat their first patient, they attend lectures, classes and hands-on labs where they learn suturing, splinting and placing lines. The orientation serves as an important bonding experience for the Emergency Medicine residents, who rotate throughout various services in the hospital for the first year and often don’t cross paths with each other for months at a time.
Where the Rubber Meets the Road
Working 80 hours a week and spending every third night on call, residents have unique access to every department and division in the Medical Center, see it at its best and worst, both day and night, and have a great perspective on what works well and what doesn’t. No one is in a better position to offer suggestions for improvement than residents.
All second-year Medicine residents and third-year Medicine-Pediatric residents participate in an eight-week quality improvement (QI) seminar that meets for two hours every Thursday. G. Waldon Garriss III, M.D., oversees the seminar and the 135 residents who participate in it.
“We start with why quality improvement is important and make a case for that. It has to do with things like medical errors. The U.S. health care system is three to eight times as deadly as a handgun. If you really want to do someone in, put them in a hospital,” Garriss said.
A group of 10-12 residents agree on a case that had a bad outcome, or could have had a bad outcome, and they have eight weeks to find a solution.
“We’ve all had one case that’s gone really sour, but if it rarely happens, we might not want to spend a lot of time and energy to fix it. However, if it’s a minor problem that happens over and over again, it’s a huge problem,” Garriss said. “We want residents to realize that they are so close to the teeth of the gears, where the rubber meets the road, they know better than anybody what’s going on and have great insight.”
The residents have successfully implemented several key changes, among them the timeframe in which patients with community-acquired pneumonia are given antibiotics.
“This hospital is judged on whether people with community-acquired pneumonia get antibiotics within four hours of coming through our door. We had some cases a few years ago when Vanderbilt was lagging behind peer institutions with that one thing,” Garriss said.
A team of residents tackled the problem and now there are prompts when a pneumonia diagnosis is suspected. When residents review chest X-rays, there is a reminder that the clock is ticking for antibiotics. In addition, the ER physicians have been authorized to start antibiotics rather than waiting for a Medicine resident to write the orders.
“It’s important for our residents to understand that medical care is no longer them and a patient behind a closed door negotiating what’s going to happen. They practice within a system. It’s a team sport,” Garriss said. “There is still some individual responsibility to make it happen. I have a message written on the resident room: ‘There’s no “I” in team but there is one in QI.’”
The Department of Emergency Medicine began using the Kaizen Toyota model, an online quality improvement system, two years ago. Since then, 1,100 suggestions have been submitted, and 80 percent have been implemented. Every suggestion is sent to Corey Slovis, M.D., chairman of the department, and he assigns it to the most appropriate person who can affect change. At every stage, the person who submitted the suggestion receives feedback. The program started with residents, now includes faculty, and is being rolled out to nurses.
“We have new intubation equipment to allow our residents to visualize a patient’s airway and project what he or she is seeing onto a screen so the attending can see it, too. I received a message from a resident before I went to work one morning that the screen wasn’t working,” Slovis recalled. “I sent it to the trauma coordinator who contacted the manufacturing representative who was in the hospital that day. He was able to fix the screen before he left at noon.”
Checks and Balances
Helping residents develop and tailor training to their own individual needs while achieving competencies to be board-certified pediatricians is the goal behind individual learning portfolios used in the Department of Pediatrics.
“One of the changes that has happened in the last five to 10 years is that residency isn’t just a set amount of time. It’s the beginning of lifelong learning,” said Rebecca Swan, M.D., Pediatric residency program director.The Accreditation Council for Graduate Medical Education (ACGME) requires individualized learning plans, and Swan has taken it a step further to make it a tool that her 70 residents can continue to use after graduation. The portfolio is a self-reflective process by which the residents review their perceived strengths and weaknesses with their faculty mentors every six months.
“It’s nice for them to have that one-on-one relationship with someone who is their mentor and not their supervisor,” Swan said.
The portfolio tracks all of a resident’s evaluations from faculty, medical students, parents, nursing and support staff.
“We used to only get evaluations from faculty, but it’s incredibly helpful to expand that. Nurses, for example, see the residents in a whole different way than faculty. The faculty doesn’t see residents talking to families in the middle of the night who call with questions and are worked up. Even our best residents get useful feedback from nurses.”
Swan dedicates 70 percent of her time to educating residents and running the Pediatric residency program. While she precepts residents in clinic, she doesn’t see any of her own patients.
“That’s the big tradeoff to being an academic pediatrician as opposed to being in private practice. I was in private practice before I came here, and I miss that, but I love the education part. It’s just fun to watch residents get confident in their skills,” she said. “I recently worked with an ER resident who was doing his first pediatric rotation, and he did a great job. Yesterday, one of the patients he discharged asked me, ‘Do you work with that really tall doctor much? Tell him I really liked him. He really listened to me.’ Residents work so hard, and it’s nice to pass that kind of comment along.”
Residents have a different lifestyle than their peers who opted for other careers. While their college classmates are working 40-50 hours a week, residents are dealing with life and death situations over the course of 80-plus hours per week.
“During residency training you don’t have as much control of your schedule. You’ve moved to a new city, and may or may not have anyone you know. As a young adult, you’re dealing with life issues like buying a car, raising a family, taking care of yourself and trying to do it around an odd schedule you can’t control,” Brady said. “Most residents become good at being resilient. They do get stressed. We try to have systems set up to share and talk about stress.”
The House Staff Advisory Council, which Terhune and Chris Kuzniewski, M.D., co-chair, allows the residents to have representation on Medical Center boards and to have regular meetings with GME staff to discuss resident-specific issues ranging from cleanliness of call rooms, to duty hours and benefits.
The Vanderbilt House Staff Alliance, which has existed for more than 20 years, is a social and philanthropic organization of residents’ spouses and significant others. It sponsors lectures, seminars and interest groups to engage the spouses and offer support. It hosts “Medical Marriages — Matters of the Heart,” a series of talks hosted by Jeff Balser, M.D., Ph.D., vice chancellor for Health Affairs and dean of the School of Medicine, and his wife, Melinda, with advice on building a strong marriage that can withstand the stress of residency.
At the heart of every residency program is the program coordinator. Betty Warner has been the Department of Otolaryngology residency program coordinator for five years. She likes to say she has 20 kids, all of them physicians.
Warner works 10-hour days and answers 75 to 125 e-mails a day, beginning when she wakes up until the time she goes to bed. She works nights and weekends for special occasions. She is responsible for making sure her residents meet all of the requirements set forth by the ACGME and Residency Review Committee. She organizes the interviewing process for incoming residents, oversees the graduation ceremony for outgoing residents and provides a healthy dose of TLC to all those in between.
“It’s like being a mother to a bunch of people to keep them on task,” she said with a laugh. “There is a lot of paperwork they have to keep up with, including their duty hours, compliance issues, vacation days, call and rotation schedules, keeping [ACLS/BLS] certifications current and making sure everyone has enough money on their I.D. cards to eat while on call.”
Warner said she particularly enjoys bonding with the residents.
“You become a sounding board for them. I’ve had female residents talk to me about boyfriend problems, and male residents talk about problems with their wives/girlfriends or their wives leaving them. I’ve had residents sit in my office and cry because they’ve had to tell a parent that their child died in the ER,” she said. “It’s such a broad spectrum of things you hear. Being there for them is very rewarding.”
First-year Otolaryngology resident, Mark Van Deusen, M.D., had been living in Nashville for just two weeks when he developed a temperature of 103.5 and signs of pneumonia. He had just moved from Syracuse, N.Y., to begin his residency and wasn’t sure where to go for help, so he asked Warner.
“Betty referred me to Occupational Health. She was outstanding in helping to ensure that I would be able to make up any orientation that I couldn’t attend. She even offered to bring me groceries while I was at home recovering. Fortunately, I was able to start my residency on time and even made all the orientation sessions,” Van Deusen said.
The residents’ study and sleep room is just down the hall from Warner’s office, so she makes sure it is stocked with linens and academic journals and tries to overlook the mess.
“I don’t, however, make their beds or change their sheets. That’s on them. Like any mother, it drives me nuts to walk in there and see it a mess, but I just let it be their mess,” she said good-naturedly.
In June she bade farewell to four graduating residents, and in July welcomed four new ones.
“When they first come here, they are fresh out of medical school and they have no specialized training, and then they leave to go into private practice or academic medicine and take care of patients on their own. It’s incredible to watch them develop over that five-year period. My residents are amazing. I love them.”