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- William W Parmley, MD, MACC*
- ↵*Send correspondence to: William W. Parmley, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 415 Judah Street, San Francisco, California 94122
I just finished one of my months of attending on the Cardiology Service and I am once again impressed by the demanding nature of that current experience. Almost 40 years ago I was a medicine intern on the Osler Service at Johns Hopkins, and I still have vivid memories of the experiences of myself and our attendings at that time. As a marker of our changing times, here are some of the profound differences between those two experiences.
There are two attendings and four house staff teams (intern plus R2 or R3) on the Cardiology Service. Frequently, we also have a medical extern or even another intern on the service. The hospital is full all the time, so there is a frantic wave of activity to get patients studied and out the door as soon as possible. There are about eight new admissions each day to the Cardiology Service. This intensifies the need to work up patients quickly and get them out the door. It is common for patients with acute myocardial infarctions (MIs) to have immediate angioplasty and go home on the third day. Rarely would one keep an acute coronary syndrome for as long as five days. Many rule-out MIs go home the same day—sometimes even before they actually come to the floor—since they are “admitted” but stay down in an overflow facility adjacent to the emergency room. I contrast this in my mind with the Osler Service of my internship at Hopkins. The patients who were admitted were definitely ill but frequently stayed for a week or two. There was time to consider all aspects of the case, time to get feedback from my resident, the chief resident, and the attending. Although it was a busy service, it was not a frantic learning experience. One of the famous pictures of Osler shows him in deep contemplation at the patient’s bedside. There is no time for that anymore.
It is common to see patients admitted in their eighties and nineties. Patients in their seventies seem like youngsters. Although we do get some patients in their sixties and, rarely, in their fifties, we are truly dealing with an older geriatric population. Frequently, this leads to major placement problems because heart disease may be only a small part of their medical problems. In my internship days, we were dealing with a patient population decades younger, with problems such as acute pneumonia, hypertensive crisis, diabetic keto-acidosis, a few MIs (for whom we had little to offer), acute asthma and obstructive pulmonary disease, GI bleeding, pancreatitis, cirrhosis, and the like. In the old days, I certainly never worried about a discussion of DNR, DNI with patients and their families—in part because they were much younger, and of course because it was not part of the required current paperwork. We currently get so many non-English speaking patients that translators become key to the evaluation of such patients. It is very frustrating not to be able to communicate with the patient or to wonder if the translation has captured the real essence of the symptoms. This is an increasing problem in our patient population in San Francisco, but it was a nonexistent problem during my internship. Discharge from the hospital also provides its challenges. First of all, trying to contact the patient’s primary physician and/or cardiologist can be difficult. Medications that you prescribe for the patient may not be on the particular formulary of the patient’s health care plan. Follow-up is not easy to arrange in relation to some tests that are scheduled as outpatient tests in order to shorten the hospitalization.
During my internship, the attending would carefully review a couple of selected patients, always taking additional history and carefully conducting a physical examination and reviewing every chest X-ray, ECG, and laboratory study. It was a time to carefully discuss an elaborate differential diagnosis and review every physical finding and test in detail. Rounds today have a frenetic quality to them. When you are presented with eight or more new admissions in addition to all of the old patients, there is no time for a prolonged and scholarly discussion on each patient. Bedside experience is limited, and it is no wonder that our house staff have lesser physical examination skills in cardiology. Our house staff frequently print out the latest information from UpToDate on individual patients to hand out at rounds: the electronic age of learning has arrived. We have instant chest X-rays in the CCU (if the computer is working). The house staff have daily conferences they must attend, which also reduces the interactive time with attendings. Having to write up a detailed history and physical examination in order to meet Medicare regulations means having the time to see each patient to do that. But patients are immediately off the floor because they are getting an echo, imaging study, catheterization, hemodialysis, or the like; so merely being able to find them before they are discharged can be a problem. It always seems so wasteful of time to me to place my own detailed written or dictated history and physical exam next to a similarly detailed history and physical exam of the intern or resident so that the department can bill for my services. The Health Care Financing Administration (HCFA) did us a great disservice when they imposed these regulations and fined institutions for noncompliance. The other attending hassle relates to the discharge summaries that are overlooked by the house staff. After a short time interval, I get the first of a series of unfriendly letters saying that on a given date my clinical privileges will be revoked if I do not get a discharge summary done. Although this is a house staff responsibility, it is very difficult sometimes to find them and actually have them do it. The only way to avoid this cancellation of privileges is to dictate the summary myself.
The house staff do not want to hear about my experiences on the Osler Service when I was on call every night but had one-half day off a week. Interns are on every fourth night and have one day in four completely away from the hospital. Thus, continuity of care is different for this rapidly changing roster of patients, when a house officer is totally gone almost two times a week. Attendings are on every other night and weekend, so I have gained somewhat since my days as an intern. Ideas such as cross-cover, night float, capped admissions, and payback were foreign to me as an intern but have certainly become a regular part of our training system currently, in part due to Accreditation Council for Graduate Medical Education (ACGME) guidelines. Our cath lab team is on rotation call every night to take almost every ST elevation acute MI straight to the lab. The trend is clear, we have been asking more and more of attendings and less of house officers. Perhaps this is as it should be, because we have shifted somewhat from house staff-run patient care to attending-run patient care. This is in accord with HCFA guidelines and also with ACGME guidelines, which state that rotations for house staff are for teaching and not for service.
Maybe these reflections will stir some memories of your own and, especially, underscore the changing environment of academic medicine. The increasing emphasis on clinical responsibilities will certainly change the type of physicians who enter academia. It will be increasingly difficult to be the complete triple threat (patient care, teaching, research) when patient care responsibilities have become so pervasive. Certain faculty will gravitate toward research only, while others will become swamped with patient care responsibilities. Certain things will remain, however, including the interactive thanks of patients well cared for and the opportunity to teach bright young students and physicians. Let’s hope these are never taken from us.
- American College of Cardiology