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Sunday, June 30, 2013

Musing on July 1 transitions

Tomorrow is housestaff transition day. Those who are completing their training are board eligible and transitioning into practice independence. An entire new crop of medical graduates of residency graduates transitioning into fellowship positions starts tomorrow.

I will generally provide a brief welcome to our program and I am slated to do so tomorrow. In giving this some thought, I recall my transition, first as an intern and then as a fellow in sub-specialty training. As an intern, I showed up on July 1. There was no orientation before July. I simply showed up and they gave me white coats and pants. We were not issued picture ID's, only a name badge which pinned on to my coat.

Upon arriving, we were directed to our teams consisting of junior and senior residents who took their new interns under their wings to their respective wards. I started in the ICU. It was a mixed medical and surgical unit with nursing staff taking direction from both surgical and medical teams. They liked the surgical patients better.

There were three new interns on my team and we were supervised by a senior resident and a recently graduated intern who was now considered the junior resident. We were briefly welcomed to our new home. We then drew straws for the first night of call. I drew the short straw and had the privilege of being on call the first night of internship. Not much else to know. There were no call quarters for sleeping. You did not expect to sleep.

All the key information on the cadre of patients under care were incorporated on to 3x5 index cards with one patient per cared. All the cards were combined and shuffled like a poker deck and dealt to the new interns. We were handed our stack and started walking rounds. When we reached the first ICU bed, a name was called and the intern who was dealt the card acknowledged their new charge.

Technology was crude. We had paper and pen. We had no pagers. All calls were send via overhead page. There were not many places to hide. Senior residents, nurses, and ward clerks knew how the hospital worked. From my recollection, they were very good at what they did but we were limited in what we could do. It was a not so complex world. We examined patients. We drew blood, We ordered simple tests, we started IV's. We administered drugs from a limited formulary, not because our hospital was poor but because there we a limited number of drugs at our disposal.

Yes in the ICU and CCU we had a few more tricks at our disposal. I put in a lot of Swan-Ganz catheters. That was before it was discovered these are generally pretty useless. We placed chest tubes and central lines. We had no ancillary teams doing that for us. Interventional Radiology did not really exist except in a few places were radiologists were toying with placing catheters where catheters had never been before.

Not so different with the transition to fellowship. I remember we had the transition from dial phones to push button. We were issued long distance codes. No longer did we require the assistance of telephone operators to call long distance. Little did I realize this was a harbinger of the transfer of tasks from support personnel to me. I did not concern myself with process. I simply saw the patient, made an assessment and wrote my thoughts on paper.  I wrote orders and assumed they were done. They were not so complex. Procedures meant I was called upon to undertake some task. I announced what I wanted to do and magically things were set up.  I did not trouble myself with how this happened.

My training happened in a Mayberry world. It was not comlpex. No one wore name tags because people don't wear name tags in Mayberry. Everyone knows who lives in Mayberry and everyone know their place.

Tomorrow, the new housestaff formally start. However, they have been around for more than a week. They have undergone a rigorous orientation at multiple sites. They have been vetted for practice at multiple sites in multiple hospitals and have been issued multiple name badges. Each hospital requires training on different computer systems, each requiring a unique set on logins; for the network, for the application, for remote access, each expiring after some period of time (usually three months), and each with a different set of stringency (at least 6-8 characters, mixture of upper and lower case with symbols, but excluding certain ones like \). Strangely enough we still have long distance codes even when the concept of what represents long distance is nearing extinction.

There are countless regulations not to fall afoul of. There is a constantly evolving set of competencies to measure up against, most of which are either irrelevant or un-measurable. The practice environments have become dizzyingly complex. The diagnostic and therapeutic options are orders of magnitude greater than anything I was offered as a resident or fellow. However, with that complexity comes the need for people and processes to deploy these options. At each step, the number of things done to of for patients has grown geometrically. They are hospitalized for shorter times where more things must be done.

It is very different. In some respects it is very different and good since we have options to save and improve lives which simply did not exist. In many respects this changed environment brings major challenges. We must face these challenges because we have no other choice. It is as much a part of the training environment than what learning the tasks I was called upon to learn as a house office 30 years ago. Hopefully the parts that bring little or no value to trainees or patients will disappear over time.

It is no longer Mayberry. It is not informal and for the most part it is not like family. It is business, complex, and behavior dictated by formal rules.

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