Who's who in the medical training world

In my last post, I alluded to different levels of medical training.  As I thought about the post later, I remembered that many of the patients I've interacted with over the years are confused about what those terms mean, and perhaps some of my lay readers are, too.

So, today I present the Singing Pen's guide to medical seniority:

Medical student = has completed a bachelor's (college) degree and is in a 4 year medical school program.  Medical students cannot independently provide any patient care; their patient notes and orders must be co-signed by a licensed physician (can be a resident or an attending).

Resident = has graduated from medical school and is training in his or her medical specialty of choice.  Residents must have medical licenses to practice and train, and a resident is rightfully referred to as "Doctor."  Graduating from medical school does not confer enough knowledge to practice independently in this day and age, though.*  Specialty training programs thus follow medical school for virtually all US med school grads; those programs are called "residencies" because, in the old days, residents actually lived (resided) in the hospital.

Intern = a first year resident.  This term is falling out of favor in some circles, as some residents and their teachers worry that it has developed a demeaning connotation.  The label persists partially because it's convenient (interns require the most supervision of all residents, given that they're fresh out of medical school) and partially because some medical specialties require a generic ("transitional") intern year program before joining their residency program (ophthalmology and physical med & rehab are two examples).

Fellow = a post-residency trainee.  Most residents go directly into independent practice after completing their residency, but some medical career paths require yet more training.  Many of the internal medicine specialities require fellowships: cardiology, endocrinology, nephrology, rheumatology, as do some of the surgical subspecialties.  Some fellowships focus less on patient care and more on academic training; I did a two-year faculty development fellowship following my family medicine residency to build my teaching and research skills.

Attending = done with training (but certainly never done with learning)!  Attendings bear the final responsibility for the trainees working with them.  Many attendings don't teach at all and just work independently, but those of us in academia work with students, residents, and fellows on a regular basis.

So, from the last educational level to the earliest:
Attending
Fellow
Resident
(Intern)
Medical student

Each level has responsibility to the levels below.  So, residents supervise medical students and attendings supervise residents' supervision of the medical students. As residency takes 3-6 years, depending on the specialty, higher-year (or "senior") residents often supervise newer residents ("junior" residents and/or interns, depending how each residency program labels its residents).

Some residency programs designate one, some, or all of their final-year residents as "chief residents" with varying levels of responsibility - from scheduling to teaching to representation - for their resident peers.  In many programs, being a chief resident is an elected honor.

Each year of medical school and then residency confers more responsibility and autonomy, ideally with the attending safety net always easily accessible.  Good attendings unobtrusively know everything that's going on with both the patients and their learners.  They gently guide the plan of care in the right direction, liberally sprinkle in teaching points, and avoid micro-managing every little detail.

I don't want to suggest, however, that the learning only moves in one direction. The constant challenge of keeping up with the latest evidence and studies is an energizing part of the job for many of us.  I learn more from the ideas and perspectives of the residents and students I am privileged to work with than I could ever teach them back.  This two-way learning makes academic medicine a very interesting place to be.

I consider myself one fortunate doc to get to teach every day, that's for sure.

* "General practice" as it used to be known in the US is no more.  Many family docs and internal med docs are frankly offended when people refer to them as a "general practitioner" or "g.p.," as these terms imply that their medical training ended after medical school (which used to be the case decades ago).  The vast majority of primary care docs in the US are board-certified "specialists" who have completed residencies in either family medicine, internal medicine, or pediatrics.

Patient comments about my age

I have gotten some interesting comments from patients regarding my age.

When I was a medical student, patients thought I was in high school.  When I was a resident, patients thought I was a college student.  Now, as an attending over five years out of residency, I get comments like "you sure know a lot for someone so young," well-intended compliments meant toward the resident I apparently appear to be.

An enviable problem to have, right?  Except I would like my patients' initial impression of me to be "professional and competent," not "nice and young."  I fear that patients will not trust me to manage their care if they think I'm so inexperienced.  I want them to have confidence in the recommendations I give them and the decisions we make together.  I have to admit, too, that a part of me wants my current station on the top of the medical training ladder to be acknowledged.

I wish it wasn't so, but it's true: I need my patients' affirmation as much as they may be looking for mine.  I'm ashamed of that confession; patients' duties should not include validating my insecurities.  I suspect, though, that I am not alone in constantly worrying about whether I am doing my best for my patients.

It's not so easy to evaluate your performance as a doctor, either.  No one is directly evaluating us, and the popular markers of success - productivity, income, government ratings - don't reflect the bulk of what our care with patients truly involves.   Patient satisfaction scores only go so far, since disgruntled patients can result when we correctly turn down unreasonable requests.  Quality improvement measures are a step in the right direction (1) but still don't answer the basic question: "did I follow the best path for this patient?"

It's all too easy to fall back on those numbers and patient affirmations to judge myself.  They each have their place in the overall picture of my practice, but I've got to center my focus on patient care where it belongs.

Just like the responsible 36-year-old I am.

(1) http://www.who.int/patientsafety/education/curriculum/who_mc_topic-7.pdf

Oliver the Cat

Have a dog, cat, or other pet at home?

Pet ownership is good for your health.  Petting a furry animal can decrease your blood pressure and stress.  Dogs are notorious for dragging their owners outside for exercise, and goldfish can be quite calming to watch. (1)

I can testify that pets are also a great help for loneliness.  When I moved to a new city for residency eight-and-a-half years ago, I was still unmarried and didn't know a single person there. Every night, my cats Mr. Tig and Oliver the Cat came to my apartment door to greet me when I got home.  They didn't care about the mistakes I had made that day, they didn't care if I was stinky from 24 hours on call, and they didn't care about my rumpled scrubs. They just loved me unconditionally, content to sit on my lap while I watched mindless television, talked on the phone, or even, occasionally, when I needed a good cry.

Those cats were my soul's balm during medical school, residency, and fellowship. They moved three times with me over those years, and their presence in the early days each time was a tremendous comfort.

Unfortunately, though, no pet lives forever.  Oliver the Cat starting losing a lot of weight about 6 months ago.  His CBC, splenomegaly, and weight loss spelled out a pretty clear picture for his human doctor owners, and we decided against any further, more aggressive work-up.  We didn't want to make him suffer through more tests and likely chemo just to squeeze out a few more months for ourselves with him.  His vets wholeheartedly agreed with our decision.

He ate less every day, and he spent increasingly more time on a soft rug in a warm downstairs bathroom.  Tig, previously inseparable from him, started keeping his distance, perhaps in recognition of Oliver's instinct for peace and quiet during the dying process.  My husband and I visited him several times a day and tried not to think of what was surely coming.

Three weeks ago, though, less than an hour after my husband and I had gotten home from work, Oliver died in my arms.

Pet grief is real grief. (2,3)  My husband keeps commenting on how empty the house feels, and Tig keeps peeking into that downstairs bathroom looking for his buddy.  I'm having trouble getting out of bed in the morning and concentrating at work.

I don't want to let the sadness trump all of the good times I had with Oliver.  I'm grateful for his presence in my life during our eleven years together, and I have lots of funny and sweet memories of him to cherish.  

Being a pet owner myself, it's been easy to ask my patients about their pets.  I keep track of my patients' pets in their charts and inquire about them occasionally. Knowing that patients with tough situations have a furry (or scaly or feathered) friend at home always eases my worry about them.  I have shared in my patients' grief over their own pet losses many times as well.  The discussions usually follow a similar outline; they share memories, I make some remarks, and then the conversation always closes with the same sentiment:

We wouldn't trade the time we had with them for anything.

(1) http://www.cdc.gov/healthypets/health_benefits.htm
(2) http://www.questia.com/googleScholar.qst?docId=5001975384
(3) http://guilfordjournals.com/doi/abs/10.1521/bumc.2009.73.3.176

And, a nice post about coping after the loss of a cat: http://cats.about.com/cs/copingwithloss/a/de

Dammit Jim! I’m a Doctor, Not an Engineer

Happy New Year from the Singing Pen.   I'd like to kick off the 2012 blogging year with a guest post by my father, Mr. Victor Middleton, who is, in fact, an engineer....

Dr. Jen, a Star Trek fan, has been known to quote Dr. McCoy’s dictum (lament or boast depending on your point of view) to her brother James whenever she requires assistance with recalcitrant computers. I am an engineer, and I find this plaint typical of the gulf between our respective professions. Doctors tend to view us as overseers of useful but often-wayward tools.  Doctors practice the art of medicine; engineers are mechanics who help take care of support details.

I’m writing this piece to try and modify that point of view and to urge a closer interaction between medicine and my particular flavor of engineering.  What I do can be classified as systems engineering or industrial engineering, or, as I prefer, operations research (OR) engineering.  

OR practitioners are dedicated to improving the operation of systems of all sorts, whether they are organizational practices and procedures, manual processes, mechanical controls and devices, computer software, or combinations of all of these.  OR as a discipline traces its origins back to World War II when engineers and mathematicians were asked to help optimize resources, including personnel and materiel, for maximum military effect. OR groups attached to the British Anti-Aircraft Command were charged with the improvement in deployment and use of Britain’s new radar network and helped win the Battle of Britain; similar groups developed novel submarine search and engagement procedures to defeat German U-boats in the North Atlantic.

The key phrase above is the “optimize resources, including personnel and materiel.”  It is incontrovertible that the health care system in the US today needs to do a much better job with respect to utilization of resources on virtually all fronts, from matters of national policy to local hospitals and health care providers.  We OR engineers can help.  

Even a cursory Internet search on health care and operations research will display a wide spectrum of ways in which OR can help docs and other health care providers, saving money through more efficient operation, but, more importantly, helping to optimize patient health care outcomes.  It would be futile for me to try to describe the extent of OR applications to health care here, but I would like to mention a few overarching principles. 

First, OR is a systems science that seeks to integrate local capabilities into more global solutions.  How do emergency room practices affect operating room availability?  How does scheduling for elective procedures affect overall hospital bed occupancy?  How must vaccination and treatment protocols be adjusted to deal with the differences between local disease outbreaks and the potential for deliberate terrorist attack?  Perhaps the best example for Dr. Jen and her colleagues would be: how does the family practice doctor help coordinate general health issues with specialist care?

Next, OR and industrial engineering seek to look at the role of systems in preventing errors.  The medical profession tends to view error as attributable to mistakes by individual practitioners.  Since we have as yet been unsuccessful in developing fail-proof individuals, a far more fruitful ground for eliminating errors is developing systems that first help avoid errors and that help identify them and mitigate them when they do occur.  Such a systems approach encompasses everything from human factors design of automated data entry and retrieval, to computer diagnostic aids, to more efficient training and re-training, and to the development of redundant procedures that check and double-check the appropriateness of treatment.

Finally, I would like to note that as engineers we share an ethical bond with physicians and their mandate: “Primum non nocere.”  As engineers, we are not impartial scientists objectively studying natural phenomena to see what makes the world tick.  Our job is to make changes to that world, and thus our ethical responsibility is to ensure that we change it for the better.  I can think of no better way to meet this responsibility than joining with medical community to address the health care needs of our country and each individual in it.

Interested readers are urged to search the Internet.  A small sample includes:

http://www.orms-today.org/orms-4-02/frmismanagement.html

http://www.wtec.org/or/report/OR-report.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3995.2010.00767.x/pdf

http://currentadvances.org/images/OrthopaedicSurgery/16_RedefineCompetition.pdf

(This last, while strictly speaking not OR, certainly expresses an OR perspective on the problems with the health care system in the U.S.)