Every Thursday morning, our practice is closed.
This seems like a strange concept, a backwards proposition, in these days of emphasizing access and always being available, and the stated institutional desire to pack in more and more patients.
Historically, this has been the morning where the Department of Medicine had our Grand Rounds series scheduled, and so the practice session that followed was foreshortened, especially when we had to get everyone out early enough for the noon conference series that followed the morning.
So, many years ago, we decided to close the practice, and built in an administrative session where we were able to schedule all our faculty meetings, curriculum committee meetings, quality improvement meetings, and give people some time to catch up on messages, phone calls, lab results reviews.
Despite the fact that Grand Rounds changed to Wednesdays several years ago, we’ve maintained this morning off as a vital feature of our practice, a nice built-in buffer where everyone gets to catch up a little bit, take a deep breath, get a little academic.
We have sublet many of the exam rooms in our practice to the Endocrinology fellows’ clinic, and they practice in our space on Thursday mornings while we are off doing other things.
To make up for this gap in access, we have opened up additional sessions, on several evenings a week and most recently Saturdays, to improve our patients’ ability to get in for essential acute and chronic care in our practice.
The “PIC Rounds”
One of the nice features we added to this morning session a few years ago was something we call “PIC Rounds.” PIC is an old acronym that once upon a time stood for “physician in charge,” and this has been what we call those attendings assigned to supervise a rotating cadre of residents in practice.
Every resident has what we call a continuity PIC, who provides longitudinal support and education to a group of residents as they go through their intern year and subsequent residency.
Every Thursday morning, we all have PIC Rounds blocked off on our schedules to meet with our continuity residents who are here on their ambulatory block rotation.
We designed this as a way for them to bring us their questions, discuss challenging cases, concerning or confusing results that they got back on testing or imaging, and to seek guidance on the next steps in the management of their patients.
Every supervising attending does PIC Rounds a little differently, some focusing on in-basket results in the EHR, some choosing a topic in advance and reviewing the current literature, others letting the cases the residents choose drive the discussion.
As we start in on the new academic year, the freshly arrived interns are plopped down into the hospital, into our practice, in the midst of a challenging healthcare environment, and have to learn to make dramatic adjustments in how they think and act as they begin their training.
We all remember that moment when suddenly we became the doctor. No longer the medical student, we were quickly and magically expected to know a lot more than we did, and carry it all off with confidence and swagger.
PIC Rounds are designed to be a place where they can decompress, talk about challenges they’ve faced, vent their frustrations, share their successes.
Learning the Ropes
Through the years, these rounds have proved to be incredibly popular, and the feedback we’ve gotten is that the residents really enjoy the time and appreciate the attention, and everyone ends up learning a lot.
Whether first-year interns or senior residents about to graduate, or one of us old gray-haired and seasoned attendings, there’s lots of learning and teaching to be had.
Sometimes the residents want to know how to handle the complex psychosocial situations and barriers brought on by social determinants of health that our patients face, and sometimes they just need to know how to order a sleep study or a CBC.
This morning, I got to meet with two of the new interns in my continuity group, here in our practice on their second rotation of the year, on the fourth day of their first ambulatory care block.
They have been met by the daunting prospect of suddenly being the primary care doctor of 100 to 200 patients, and for the most part they seem to be rising to the challenges and relishing these new roles.
Unfortunately, we had to spend a lot of the morning going through functionality in the electronic medical record, dealing with in-basket results, portal communication messages, delineation and configuration of coverage issues, and just plain old figuring out what they were responsible for and what somebody else needed to do.
“When a patient doesn’t show up for an appointment, how do I contact them, and how do I make sure a follow-up is scheduled?”
“When the message says the patient needs a refill, but it doesn’t say of what, how do I know what to do next?”
“Why are there so many different in-baskets, how do I learn to manage them, and why does each one of them have so many gosh-darn messages in it?”
Making it About the Doctoring
In a way, the functionality of the electronic medical record can make the documentation needed for the care of patients easier, and when it’s used appropriately, it can probably end up creating a better communication tool than the old paper charts we used to have.
But there is so much stuff there, so many in-basket folders to check, so many different ways to release the results in the portal and communicate results to patients, that when these excited new learners are just starting to figure out how to be a doctor, it’s no surprise that this extra burden of learning how to maneuver in this environment can make the job of being a primary care doctor seem less than ideal, less than the amazing thing that it actually is.
As we continue the work with our institution to build out the necessary support to have a true, fully functional, effective and efficient, patient-centered medical home, I can only hope that we remember that these new arrivals, just recently entered into the field, need our support, need a world of resources around them helping take care of the things that aren’t really about doctoring.
I don’t want them to become experts on clicking boxes, on filling out reports that fulfill only bureaucratic needs instead of directly helping patients, and it’s bad enough that we spend a large part of our welcome orientation teaching them how to do the documentation necessary for compliant billing.
Left to our own devices, the attendings, all of us clinician educators dedicated to the mission of teaching the next generation of physicians, would love nothing more than to put our energies and our hearts into teaching, into guiding these new doctors, and taking them under our wings as true apprentices, to inspire them to a life in primary care.
And as I see the excitement in their eyes as they are starting out, we all need to rededicate ourselves to demanding the best for them — a system where they can practice up to their license, where all the rest of this stuff happens in the background, and they can learn the joy of taking care of patients, of sitting and listening to them, exploring their lives, holding their hands, helping them overcome the barriers to their health, exploring the social determinants of health that may be preventing them from getting care, opening up research opportunities, and inspiring them to work on innovative new models of care.
If not, then the system we’ve let be built around us is destined to turn them off to the life of a primary care physician, and that would be the shame of it all.
Source: MedicalNewsToday.com
