Guest Post: Musings on General Medicine at a Teaching Hospital

The Following Post is Written by Dr Deborah Fisher, Associate Professor of Medicine, Division of Gastroenterology at Duke University Medical Center.  Dr Fisher is both a brilliant clinician, writer, and researcher…and also happens to be my wife. http://www.durham.hsrd.research.va.gov/cv/Deborah_A_Fisher_MD_MHS.asp

Usually I spend about 65% of my time in clinical Gastroenterology and 35% in research, but 4 weeks a year I put on my General Medicine hat and supervise the housestaff.  General medicine is more challenging than ever because of resident time restrictions, multiple patient care hand-offs, and the increased administrative burden for all physicians (in-training and supervising). For readers not familiar with the academic calendar, it runs roughly July to June rather than January to December. This past General Medicine rotation I drew the lucky card of July.  Or so several administrators would have me think.  “Residents are enthusiastic in July, no burn-out” “They don’t argue with you” “They treasure every clinical pearl you offer” and the like.  Perhaps.  I must admit that residents rarely argue with me during any month and often General Medicine induces burn-out in even the newest residents.

Nonetheless, I thought it might be less pressure to teach in July.  The classic Chalk Talk is all but gone.  Allegedly, residents are all self-teaching basic pathophysiology and differential diagnosis during the time carved out by duty hour regulations, but the empiric and published evidence is not obvious to me.  My teaching goal is to bring relevant data to the clinical setting in the context of individual patients. Of course, I provide feedback regarding data collection, patient presentations, and plans for management, but I also emphasize the importance of communication: within the team, with covering physicians, with consultants, and with patients and their families.  I teach critical appraisal of guidelines. Guidelines can be useful summaries of the available data, but they can also be biased opinions and above all they cannot be applied to any patient without considering how that patient may have complicating comorbidities or other circumstances not addressed in a given guideline. Finally, in all clinical settings, I emphasize that in this age of technology we must connect with our patients and engage them in their own healthcare. I worry when in clinic residents only make eye contact with the computer screen or on the wards when, after morning rounds, they deliver all news to patients via bedside telephone (even when on the same hospital floor and wing). The Mantra from Administration is “Discharge planning begins on admission.” My interpretation is that we are not attempting to discharge as quickly as possible for its own sake, but that we must understand something of a patient’s social situation and other potential barriers to managing their health to start mobilizing resources to address these barriers. The sooner this is done the better.  We must tailor the evidence for an intervention with the individual needs of the patient.

To avoid taking myself too seriously in my role as a clinician-educator I will end by sharing my 2 super powers.  This is timely as July is also filled with superhero summer blockbuster movies.  My best super power is the ability to arrange endoscopic procedures with a single phone call.  My second super power is the ability to approve Miralax (polyethylene glycol) for constipation.  Oh the might! The glamor!  Of a Gastroenterologist on General Medicine.

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