California Pacific Currents 2004
For Residents, Two Special Clinics Offer Unique Learning Opportunities
As part of their clinical training at California Pacific Medical Center, many residents expand their knowledge while serving the community through the Family Health Center or the Lions Eye Foundation Clinic. These clinics offer California Pacific’s residents hands-on experience in treating patients from a spectrum of socioeconomic, cultural, and ethnic backgrounds.
The FHC: Building Relationships
California Pacific’s Family Health Center (FHC) handles about 28,000 patient visits a year with services in internal medicine, pediatrics and gynecology, as well as surgical and medical subspecialties, according to Joyce Hansen, MD, Director of Adult Medicine.
“The clinic is a unique resource for a private training program in that it simulates a real-life practice experience,” Dr. Hansen says. “The residents learn the ropes so they can make an easy transition into their own careers; they are supervised but assume responsibility themselves.”
Typically, residents work with attending physicians in teams of about four. Residents review their patients’ records, then interview and examine them, and present the results to the attending physician for review. If attending physicians are unclear about a point or want more information, they may then see the patients themselves.
One of the most important aspects of the program is that it creates continuity for both residents and their patients, according to Tom Baudendistel, MD, Associate Program Director for the Internal Medicine residency.
“Improving continuity allows residents to assume more ‘ownership’ of their patients,” Dr. Baudendistel says. “That benefits patients, who get to know one resident as their primary care physician. And the residents get to see a patient they know, so they can plan their preventive care—scheduling things like mammography, colonoscopy, or cholesterol screening—instead of just making sure that nothing serious is going on.” For resident Damon Kwan, MD, continuity is one of the most satisfying aspects of his training. “Patients come to the clinic and say, ‘Dr. Kwan is my doctor,’” he says with evident pride. “That patient-physician relationship is a key, integral part of the clinic. You build on it throughout the three years, and at the end it is actually tough to let go, for both the patient and yourself.”
The curriculum is changing to reflect the evolution of training and patient care. Among the didactic aspects of a resident’s education are weekly clinic conferences and instruction in evidence-based medicine, which emphasize treatment according to protocols that have been explored and determined sound in clinical trials. Two new faculty members, Daniella Zipkin, MD, and Debbie Lindes, MD, will help teach these aspects of care. “It’s exciting to work with faculty as well qualified as these physicians,” Baudendistel remarks. “Residents need to accurately assess the myriad articles that inundate them and separate the wheat from the chaff.”
“The approach helps residents ask good clinical questions, arrive at answers, and know what to do with the information they find,” Dr. Hansen adds. “The thrust in medicine now is to make interventions that are based on good clinical evidence as much as possible.” She cites the recent shift away from hormone replacement therapy for postmenopausal women as a classic example of how practice changes when better studies became available.
The Importance of Communication
Training in doctor-patient communication has come to the forefront in residents’ training at the FHC. Residents work with attending physicians and a psychiatrist to learn techniques for delivering bad news, for example, or for approaching self-destructive behaviors such as smoking. Doctors must also learn to deal with patients who somatize—that is, express unresolved psychological issues in physical symptoms. Dr. Hansen also notes how important it is to discern a patient’s emotional status.
Dr. Kwan has already experienced such issues firsthand. He had a patient who was so frightened of doctors that at first she wouldn’t even let him touch her with a stethoscope. “For several meetings we would simply sit and talk, trying to hammer out what those barriers were,” he says. “Really, she just needed someone to listen to her, and our last session ended with a big hug. That’s the kind of experience the Family Health Center allows us to have.”
The Lions Eye Foundation Clinic: High-Quality Care for the Needy and Uninsured
California Pacific’s ophthalmology residents enjoy a unique opportunity to further their training while serving the community by practicing at the Lions Eye Foundation Clinic. The Foundation supports the clinic, identifies and refers prospective patients, and provides a variety of services for the residents. Patient visits totaled over 2,900 in 2003, and clinic physicians perform 150 surgeries a year, of which roughly three-quarters are patients referred through the Lions, according to Mark Paskvan, the Lions Program Coordinator.
“We are primarily a surgical clinic, and the patients referred to us have already seen a doctor,” Paskvan says. “If they’re not here for surgery, it may be because of something long-term but urgent such as glaucoma, for which they require treatment and medications that we can supply.”
Paskvan explains that the patients come from a wide geographic area—including northern California and
Nevada—and do not have health insurance. This referral source offers residents a chance to help people who might otherwise have gone without care. It also presents special treatment challenges, because patients have often put off seeing a doctor, resulting in more complicated conditions.
“We see patients who are migrant workers, a lot of kids with strabismus (misaligned eyes), and people who have lost their jobs or fallen through the cracks,” Paskvan notes. “There’s a large group from age 55 to 65 who cannot find work or have lost their insurance, and there are many casino workers from Nevada who are not offered insurance. We try to help them all.”
Community and Cooperation
“I think the Lions Eye Foundation Clinic exemplifies the portion of the hospital’s mission that deals with community service and education,” says Susan Day, MD, Program Director and Chair of California Pacific’s Ophthalmology Department. “The clinic provides high-quality care for patients who otherwise would have none, and our residents see the full array of clinical circumstances they’ll be faced with when they complete the program.”
When patients arrive, it can be an emotional experience for all, according to Mark Paskvan. The patients not only may have delayed seeking treatment until their conditions are
serious; they may also have concurrent and complicating conditions such as diabetes.
“It isn’t unusual for patients to be led into the clinic for the first time,” Paskvan says. “Usually their eye condition has progressed to the point that they can’t stand it anymore or simply can’t see. We find cataracts that have gone all the way to white; we see retinal detachments—which you ideally want to treat within 48 hours—that they’ve been living with for a year. So the residents are seeing a more advanced form of the things you’d find in private practice, and surgeries can be more difficult as a result. Nevertheless, our outcomes have been very, very good.”
One reason for the good results, of course, is the quality of California Pacific’s faculty and the residents themselves. According to Erich Horn, MD, Associate Program Director, newcomers begin their residencies with four months in the clinic, under the supervision of the chief resident (the most senior resident who handles administrative tasks such as surgical scheduling as well as clinical practice). “The two of them work cooperatively, along with an attending physician, to learn the clinical exam and all of the skills necessary to correctly diagnose and treat diseases of the eye.”
The new resident also observes the chief resident during surgery, assisting as needed. When most of their training is completed two and a half years later, they will shoulder those responsibilities as chief residents themselves. Dr. Horn explains that the system guides the residents to professional maturity, one challenge at a time. He should know, having done his own residency at California Pacific. “When you come back as chief resident, your role is to be the surgical provider and direct the medical care of every patient,” he says. “It’s a big responsibility for someone who has come full circle in that time, but now they’re ready for the responsibility.”
“It’s a great learning experience because these patients are referred by ophthalmologists, so we’re not doing a lot of basic screening exams,” says Philip Penrose, MD, a California Pacific ophthalmology resident. “In other programs you may get a lot of patients without eye disease, but we are really seeing pathology. There’s something to learn from every patient, so you can fine-tune your clinical exam.”
Dr. Day sums up with these sentiments. “It’s a fabulous win-win situation in that the patients get help, young doctors get trained, community ophthalmologists can contribute to the betterment of their profession, and the hospital can fulfill its mission of community service,” she says.