Published in the October 2009 issue of Today’s Hospitalist
Just three short months ago, when Harshal Sheth, MD, was a third-year internal medicine resident at the University of Chicago, it seemed like everyone in the hospital “particularly ED physicians “had no problem telling him what he needed to do to care for any given patient.
Fast forward to MacNeal Hospital in Berwyn, Ill., where Dr. Sheth began practicing this summer as an ICU hospitalist. Now, he explains, “Everyone listens to anything that I say, and they hold my word to be gold on these patients.”
That newfound sense of authority has come as a pleasant surprise, but it can at times be daunting. While Dr. Sheth now has the respect (and rapt attention) of the hospital’s senior physicians, he’s not very far removed from training.
He’s not alone. While many physicians fresh out of residency have the clinical chops they need to care for patients on their census, there are a host of issues that new physicians are less prepared to handle. As a result, the transition from residency to practice can have some rough spots.
The medicine may be the same, but working as a team of one, rather than as part of a team of residents and attendings, can be a big adjustment. Being the lone decision-maker is a particular eye-opener when physicians have to navigate the business and socioeconomic worlds of medicine, fraught with payer denials and family demands, by themselves.
Check our new Editor’s Blog: New physicians face obstacles in hospitalist careers
Staying on a first-name basis
For Dr. Sheth, one mildly jarring adjustment has been getting used to older nurses who insist on calling him “Dr. Sheth” instead of the “Harshal” that he prefers. (Younger nurses, on the other hand, have no problem being on a first-name basis.)
But the biggest adjustment to being an ICU hospitalist without critical care training, he says, is serving as “the last line of defense” on any patient care issue. Even much older, more experienced attendings and subspecialists in the community teaching hospital where he practices often defer to his judgment.
“They are filtering down to me any problem with any patient, which was an adjustment at first,” Dr. Sheth explains. “I’m the one called upon to take charge.” While he’s only one phone call away at any time from a critical care attending, he proudly notes that he’s used that lifeline only once in three months.
Another surprising aspect of his transition was the number of patients he sees per shift. As a resident, he would see six or seven; as an attending, that number is more like 15.
“My responsibility level,” he says, “is, I guess, four-fold what it was as a resident just a few months ago.”
But not everything about the transition has been rough. Take his schedule: three 12-hour days on, then four days off, on top of having paid time off. Now that his boards are out of the way, Dr. Sheth is planning trips this winter to both Belize and Brazil, and he’s looking forward to taking up a few things that he used to enjoy before training: reading books and playing baseball.
Different patients and resources
For Cory Garten, DO, who finished internal medicine training at Pontiac Osteopathic Hospital in Pontiac, Mich., in June 2008, his first year at Porter Adventist Hospital as part of a Sound Inpatient Physicians group in Denver has brought him many more, not fewer, clinical resources.
For one, he’s no longer treating an inner-city population plagued with widespread drug abuse and severely restricted access to care. “In residency, I’d see much more noncompliance,” Dr. Garten says. “I can worry less about the availability of outpatient follow-up and access to medications.”
And unlike physicians trained in a university setting, he now also has access to many more modalities, including PET scans and MRIs. “We have interventional radiology to do thrombolysis, which I didn’t have as a resident,” says Dr. Garten. “We’d usually transfer these patients out to a big trauma center.”
Jacob Dexheimer, MD, who finished training in June, now calls for many more consults than he did as a resident. For him, one of the most pleasant surprises about the transition to practice is how much subspecialists appreciate his business.
“Almost universally, the consultants are happy to talk to you,” says Dr. Dexheimer, who now practices with the Saint Thomas Hospitalist Group at Saint Thomas Hospital in Nashville. “In an academic setting, it’s often a resident or a fellow who you’re asking to do more, and it’s just more work that they’re probably not going to be paid for.”
A new view of turf
Some physicians likewise bring that sense of turf with them from residency, says Thomas Tesauro, MD, an assistant director of the hospitalist program at Saint Thomas, who’s seen the group grow since 1998 from five to 24 full-time equivalents. (At least half of those additions, Dr. Tesauro adds, are “like Dr. Dexheimer “residents from Vanderbilt.)
“As a resident, when you’re told to go see a new patient, you may think, ‘That should be the neurosurgeon’s patient, not mine,’ ” he says. But in a private hospital, the issue of turf can be different.
“We encourage new doctors to focus not only on the patient as their primary customer, but other services as customers too,” says Dr. Tesauro. “Don’t argue about who should care primarily for a patient, just try to be more service oriented.”
Dr. Dexheimer says he has no problem with that service orientation; the problem is knowing which consultant to call. One difficult aspect of transitioning from residency to practice, he explains, is the fact that you no longer know everyone where you work.
“Our cardiology group is very big, so it’s hard to get to know everybody,” he points out. “It’s challenging to establish so many important relationships so quickly.” But an even tougher part of the transition is not having a proscribed role on a team. “You used to be responsible for only a part of the care, but now you’re responsible for the whole puzzle,” says Dr. Dexheimer. That’s an especially hard adjustment when coupled with the realization that, often, “the patient issues that aren’t medical turn out to be bigger issues than the medical ones.”
It’s been difficult, for instance, dealing with factors that can be big barriers to getting patients out of the hospital. “The family may want the patient to go home, or the family may want the patient to go to a skilled nursing facility,” Dr. Dexheimer says as an example. “As a resident, those issues were all spread around, but now it all comes back to you.”
The finances that drive medicine
That’s part of the frustration that comes from learning how much medicine is dictated by financial realities, a problem that can no longer be shared by other members of a team.
In 2006, George Mekhjian, MD, came out of residency and starting practicing with the IPC The Hospitalist Company group in St. Louis. Three years later, he’s now practice group leader for the IPC hospitalists at Saint Anthony’s Health Center in Alton, Ill., and has been in charge of orientation for four new physicians coming on board right out of residency. (The IPC group in St. Louis serves nearly 15 hospitals, and the hospitalists in each facility have their own practice group leader. Dr. Mekhjian’s group includes four physicians and a nurse practitioner.)
To make his new doctors’ transition run more smoothly, Dr. Mekhjian gives each of them his cell phone number and invites them to call any time. He finds himself fielding many of the same questions that used to frustrate him when he first started practicing.
“You know the patient needs rehab, but all you get is calls from the insurance company saying, ‘We will deny this and we will deny that,’ " says Dr. Mekhjian. “You come out of residency with no exposure to the financial factors driving the hospital business, and you think that whatever you want for the patient will happen. The fact that it won’t is very frustrating and challenging.”
The best way to handle those denials, says Dr. Mekhjian, involves other steep learning curves for young physicians: providing excellent and full documentation, as well as knowing how to access resources including case managers, social workers, and physical and occupational therapists.
Despite that frustration, Dr. Mekhjian adds, many physicians transitioning to hospital medicine come to really appreciate the lifestyle, one that even physicians intent on finishing a fellowship find compelling.
In his graduating class from St. Louis University, for instance, almost half of the internal medicine physicians opted for a hospitalist position, although a few of those considered a year or two of hospital medicine as a way station before fellowship.
Now, however, Dr. Mekhjian says that several who first planned to head to fellowships have opted to stay in hospital medicine instead.
“The flexibility of being a hospitalist,” notes Dr. Mekhjian, “is incomparable to any other practice.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Tips to ease the transition
ONE WAY TO ENSURE a smooth transition from residency to practice is to do your homework before you pick a practice and to avail yourself of the experiences of residents who have gone before you.
Harshal Sheth, MD, says he took advantage of that inside track when he finished his internal medicine residency at the University of Chicago. He took a job as an ICU hospitalist at MacNeal Hospital in Berwyn, Ill., for a year before starting a fellowship.
“The biggest help was talking to people who had come through my residency program and done my job, including one who finished right as I started,” says Dr. Sheth. “She obviously knew where we came from, and she made it very comforting that this wasn’t going to be an entirely new culture and a shock to me.”
Other physicians say they opted for positions within national hospitalist management companies, in part so they could rely on the infrastructure that comes with very well-established programs and companies. That was the case for both Cory Garten, DO, who started practicing in Denver with Sound Inpatient Physicians, a 400-member national hospitalist company, and George Mekhjian, MD, who began working out of residency with the St. Louis group of IPC The Hospitalist Company, the country’s largest hospitalist provider, a few years ago.
“We have a great billing system, which reminds you of everything you have to do, but you need the human resources,” Dr. Mekhjian says. “We can call 24/7, and there is a person to answer any question.”
For Jacob Dexheimer, MD, who just started practicing this summer with the Saint Thomas Hospitalist Group at Saint Thomas Hospital in Nashville, one of the most helpful factors in making the transition has been the physical set-up of the hospitalist service.
The physicians all use one large, open area the size of “a couple of conference rooms,” Dr. Dexheimer says, with low-walled cubicles for physicians’ computers and work stations. This is where the hospitalists congregate as they’re coming on and off their shifts, and it’s where they make phone calls to consultants and referring physicians.
“You just shout out to the open area, ‘Hey, how do you get this done?’ and you get three or four answers back immediately,” he says. “You’re never here by yourself, and it’s like having a group of mentors.”
Most groups offer new physicians several hours of orientation, with perhaps two days of shadowing another hospitalist before they take on their own case load. According to Thomas Tesauro, MD, an assistant director of the hospitalist program at Nashville’s Saint Thomas, one big adjustment that doctors out of residency at Vanderbilt University have to make is that the hospitalist service “is five years behind” what newly graduating physicians are used to as far as electronic health records and computer physician-order entry.
And while physicians out of residency have a full set of clinical skills, they almost universally have not received any training in what Dr. Tesauro says is “a pretty huge area”: billing.
To help smooth that transition, Dr. Tesauro says each newly hired physician gets a pocket card listing standard billing codes.
As part of physician orientation, he also walks them through a software program (www.crediblemed.com) developed by one of the group’s hospitalists that can be downloaded on the physician’s handheld. Dr. Tesauro also spells out the group’s typical spread of billing codes.
“I tell them the percentage of higher level admission and subsequent visit codes, and what our percentage of extended discharge vs. regular discharge codes is,” he says. “That, along with the software tool, gives them an idea of what’s appropriate.”