Tuesday, August 14, 2012

Why I left academic medicine

A medical student who thinks he wants a career in academic surgery asks, “You were deep into academic medicine and walked away from chairman, program director, etc. Why?"

[Background: For over 23 years, I was a full time surgical chairman and residency program director in three different community hospitals affiliated with medical schools.]

Good question. For many years I had always said something like, “No matter what crisis happens with the residents or the chairman’s job, it pales in comparison to having a patient with a complication.” In other words, non-clinical problems were annoying but manageable.

Then one day I realized that was no longer so. Patients with complications still caused me many sleepless nights and that hadn’t changed. What had changed was that resident issues and administrative hassles finally became intolerable.

The rules set by the accrediting bodies, the ACGME and the Residency Review Committee [RRC] for Surgery, had always been difficult to comply with, especially for a small program. They became more onerous every year or two until it reached the point where I can’t imagine how anyone can stand it. Residents can complain to the RRC anonymously and no matter how factually you refute the complaint, the RRC always believes the disgruntled resident. Add in the work hours rules and the lack of motivation of some of today’s med school graduates and I had had enough.

The position of surgical chairman in a community teaching hospital is like that of a football referee. At any given time, half your constituency is not happy with you. The administration pays your salary and expects you to spout the party line. But you need your attending surgeons to treat the residents well and support the program. Many times you have to make decisions that are guaranteed to alienate many people.

A lot of energy was spent investigating complaints. Families were unhappy with the residents; attending surgeons were unhappy with the residents and conversely; nurses were unhappy with the residents and/or the attendings; someone was rude to someone else; someone shouted; someone cried and on and on.

And the site visits. Drop everything; the state is here to investigate a case or the state is here to interview the residents about their work hours. The Joint Commission is coming in six months. We need to meet twice a week to make up for all the unnecessary but JC-mandated stuff we haven’t been doing for the last two-and-a half years. Countless hours were spent buffing up the paperwork for an RRC site visit. I think that’s where I learned creative writing.

And the meetings. Risk management meetings could last three hours during which time you would have the opportunity to try to explain why a surgical complication occurred to a room full of non-surgeon MDs and non-physician administrators. We used to deal with this sort of thing quite effectively at morbidity and mortality conference.

Then there were the committees. At one of my former hospitals I was either chairman or a member of the following committees: Pharmacy, Critical Care, Infection, Medical Executive, Operating Room, Surgical Performance Improvement, Strategic Planning Work Group, Product Evaluation, Library, Clinical Leadership Group, Cancer, Trauma, Budget, Graduate Medical Education, and Risk Management. I’ll save you the trouble. That’s 15 committees.

For a long time, I enjoyed being a residency program director. I am proud of the more than 50 chief residents I helped train. I view them as my legacy. I regret that running a program and teaching residents stopped being fun a few years ago. I also liked being a chairman until medicine took a turn toward the dark side.

I could go on but this post would reach 20,000 words.

So my young friend, think long and hard about that decision to become an academic chair.

Wednesday, August 1, 2012

Who should place a Foley catheter?

A nurse who understandably asks to remain anonymous writes, “In our hospital, we have an increased catheter-associated urinary tract infection (CAUTI) rate related to poor skills by medical residents. The surgical nurses want to insert the caths, but the residents jump in and do not perform the skill correctly. Feedback please.”

Thanks for the interesting query. Several thoughts come to mind. I can understand a new resident wanting to learn how to perform this procedure. But after doing a few, I think that the novelty would wear off, especially at 3:00 in the morning. Also, it is likely that the nurses would be able to do it in a much more timely way.

In my current hospital, which is non-teaching, nurses place Foley catheters without incident or opposition. I don’t know our rate of CAUTI, but I doubt it is high.

You might try the direct approach and speak to the residents when they don't do it right, but unless they've read my "Hints for new residents" blog where I mention that you can learn a lot from nurses, they may become indignant.

I assume you have some data to back up your assertions that your CAUTI rate is high and can document that the residents are not doing it correctly. Having dealt with teaching hospital politics for many years, I suggest the following to you.

Speak with your nurse manager and the nurse who does clinical education and tell them what the specific problems are. For example, are the residents not adhering to sterile technique? Are they not following the steps properly?

The nurse manager and clinical specialist should talk to your infection control nurses and their supervising physician, who should then discuss the matter with the residency program director. This will keep you out of the line of fire and not jeopardize your relationship with the residents.

This process is good way to handle any sort of conflict. In the military, it is known as following the chain of command.