California Pacific Currents 2003
In Internal Medicine, Residents Learn Diversity, Depth, and Dedication
Paul Aronowitz, MD, Tom Baudendistel, MD, Jodi Langsfeld
California Pacific Medical Center’s internal medicine residency is built on a unique combination of strengths that help provide a thorough and humane graduate medical education for its 56 participants.
“The program really offers a wealth of clinical education,” remarks program director Paul Aronowitz, MD. “We have an extremely diverse population of patients—racially, ethnically, and in terms of diagnoses—so residents see the spectrum of what internal medicine really is.” Even if residents don’t go looking for diversity, it tends to find them. In one day they may deal with a liver transplant patient, then with emergency spillover from San Francisco General Hospital. They’ll treat indigent patients without insurance, those on Medi-Cal, and elderly patients from such a wide income range that they may arrive by bus or by Bentley.
Meeting Challenges…and Providing Them
The residents themselves aren’t the only ones who gain by the experience. According to Allan Pont, MD, Chair of the Department of Medicine, training programs also attract better physician educators to the hospital. “People of very high quality like to practice in a stimulating environment,” he explains. “There’s nothing more stimulating than residents who are asking difficult questions, who demand that you keep up with the latest advances in the medical literature because they do.”
Dr. Pont added that training top-quality residents also helps California Pacific replenish its supply of primary care physicians at a time when many medical graduates are choosing specialties rather than internal medicine due to disparities in pay.
The program recruits 28 residents annually. Typically, half of those will continue training in internal medicine after the first year, while the other 14 will move on to subspecialties such as anesthesia, dermatology, or radiology. “Our preliminary (first-year) program is popular but tough, because our hospital provides both primary and tertiary care,” Pont explains. Those who finish three years in internal medicine may then do fellowships in these or other specialties, as well.
Hands-On, In-Depth Experience
The hands-on approach in the California Pacific program offers great opportunities to those suited to it, according to Dr. Aronowitz. “The core teaching faculty is tremendous,” he says. “They love taking residents to the bedside and teaching them. They love coming to morning report.” That daily conference, at which residents present cases to each other and discuss them, gives seasoned teaching physicians a chance to review how their charges are handling challenging situations. It also gives the residents a chance to question and learn from each other.
“There is nothing like a real patient to bring issues to the fore, to focus attention and learning,” Dr. Aronowitz comments. Discussions may explore a common problem that has presented in an uncommon way, an unusual medication side effect, a curious finding in an X-ray, or nearly anything else. “The morning report offers residents a chance to examine how a patient was managed and to raise quality-assurance issues without someone feeling criticized or under the gun,” says Dr. Aronowitz.
Changes in the Wind
Several changes have ameliorated the boot-camp reputation of medical residency. At California Pacific, internal medicine residents take one-month stints to investigate research or subspecialties that interest them. First-year residents get two of these a year; second-year, three; those in their third year take four. Residents may also stay for a fourth year as chief resident.
Beyond that, however, changes promulgated by the Accreditation Council for Graduate Medical Education (ACGME) limit working hours to a mere 80 per week—no more than 30 straight without a 10-hour reprieve—and impose other restrictions. Hospitals don’t flout the new rules; ACGME inspection is a thorough and rigorous process, and the council has the power to shut down noncompliant programs.
In any case, at California Pacific the changes haven’t posed much of a problem, according to Tom Baudendistel, MD, Associate Program Director Internal Medicine. “We adhered to 95% of the changes before the official deadline, so we are not as affected as some,” he notes. Through the national program directors’ list-serve, Dr. Baudendistel has received a flood of e-mails from program directors around the country inquiring as to how a residency program, such as California Pacific’s, has adapted. “House staff has more night-float rotations, in which a resident does a 12-hour shift from 7 p.m. to 7 a.m.,” he says. “There’s also more attending and high-level backup in-house, and there’s always a hospitalist [an inpatient specialist] here now.”
The new rules will help residents who face a more acute patient load due to the limits on hospital stays mandated by insurers and changing practice guidelines. Dr. Baudendistel comments, “Hospitals are more efficient at utilizing their beds, so when a resident is looking after 8 or 10 patients, they are actively sicker than hospitalized patients were a few years ago. During the majority of call nights, residents are going to be reaching the limit of patients they can care for.”
From the Residents’ Point of View
For their part, California Pacific’s residents seem to appreciate how good they’ve got it and, in turn, are highly dedicated to their program. Because they’ve attended medical school elsewhere, they have a basis for comparison, and they like what they find here. “I love this hospital,” says Wendy Leembruggen, MD, who is in the second year of her residency. “I’ve found it to have the best balance between a university hospital and a private one. I really appreciate the ‘Learn with love, not with fear’ attitude. ”Dr. Leembruggen says that not only is the teaching first rate, due to faculty and attending physicians who come from academic backgrounds, but California Pacific’s ancillary services are exceptional. “The nurses are great, there is less hierarchy, and there’s a lot of respect between nurses and residents. The patient-transport system is excellent, and our nutritionists are superb.”
Dr. Leembruggen has surveyed her med-school friends who landed at other places and has been shocked at how miserable they are. “I’m having the best experience,” she remarks. “I have friends who don’t even get called by their names; doctors just call them ‘Intern.’ This was my first choice for residency, and I can’t imagine myself anywhere else.”
Happiness and a Dedication to Excellence
After a medical school experience she terms “unfriendly and hostile,” Lauren Friedly, MD, was on the verge of leaving medicine altogether. At the last minute, however, she heard about an opening at California Pacific, talked to a couple of people in the program, and decided to give it a shot. She’s now in her third year, has no regrets, and anticipates staying for another year as chief resident. “I love it here because it’s friendly, comfortable, collegial—it is really all about taking care of patients on every level, from the faculty on down.” The general atmosphere of support and respect helps tremendously. Dr. Friedly adds, “The attending physicians are outstanding doctors and great teachers—energetic and very available. They’re close enough to their own residencies to remember what it was like, and they enjoy working with residents. They also give amazing patient care.”
Life after California Pacific
Those who finish the program and want to move on to fellowships are helped by a network that starts with those teachers, according to Dr. Pont. “It’s been very easy for us to get fellowships for our residents because there are many famous faculty here,” he says, noting that the situation is atypical for a community hospital.
Dr. Pont was chair of the ACGME’s internal medicine residency review committee for two years and has the connections to help his residents get placed in the fellowships they want. It’s all part of what Jodi Langsfeld, California Pacific’s Director of Medical Education, calls trying to be responsive. “You have to go a step beyond,” Langsfeld says. “You have to be there and make your residents feel as though somebody cares about them.” Apparently they’ve gotten the message.