Transition to Residency

Transition to Residency

On Wednesday I was on the hospitalist medicine team for General Internal Medicine (GIM).  On the team, there was the attending staff, a fellow that was doing Emergency Department (ED) consults with me and ICU transfers, and another fellow rounding on the team’s inpatients. This was a unique experience for me as it was the first time that I have been involved in day-time ED consults and admissions for GIM.  It is entirely different as you have many of the day-time resources available and this changes the options you have available for patients’ disposition plans. 

One of the cases that I saw was a patient who presented with symptoms of a few days of lower limb pain.  Despite the pain, she was improving and was still ambulating.  After doing my consult, she brought up to me that she did not have coverage for hospital costs or medications.  As I was coming up with my plan before reviewing with my staff, I was thinking about how to best balance a few things: the patient’s wishes, what we think may be medically necessary, and resources.  When ordering further investigations, we thought carefully about the rationale for our tests and which ones are medically necessary and would change our management.  For example, ordering a lower leg ultrasound to rule out a deep vein thrombosis was something that was acutely relevant.  In terms of a connective disease work-up, we ordered a few higher yield investigations but an entire work-up at present was not warranted given the clinical picture.

We had one of our subspecialists see the patient and their team deemed that this was a transient episode, and we planned for her discharge from the ED.  In managing this patient throughout the day, I felt that I had a lot of resources at my disposal to make a safe discharge plan while considering her situation holistically (namely her health coverage limitations) and still ruling out worrisome causes of her presentation.  Our social worker came by to see her with regard to providing resources to cover her hospital costs.  I counselled the patient on reasons to return to the ED and gave her a list of over-the-counter pain medications that she can use (with maximum doses and side effects explained).  She had the contact information of a subspecialist in case her symptoms did not improve.

Making safe decisions with regard to admission versus discharge and counselling patients are skills that develop over time and I was afforded the opportunity to practice that during my day on hospitalist medicine.  Transitioning to residency will be challenging as we develop more autonomy and responsibility – there will be more difficult conversations and decision-making on a regular basis.  A study from UCSF’s School of Medicine, looking at their transition to residency course, showed that students found the course helpful for: recognizing unstable or sick patients, identifying help and backup, communicating effectively, teaching others, maintaining well-being, understanding resources, and carrying out daily patient care responsibilities.  (Teo et al., 2011) This highlights the importance of our current Transition to Residency course which includes lectures, rotations, and assignment thats have a large impact on preparing us for what is to come!

SH

Resources:

Teo, A. R. et al. (2011). The Key Role of a Transition Course in Preparing Medical Students for Internship.  Acad Med, 86(7): 860 – 865.