The Disconnect Between Residency Training and the “Real World” by Jan M. Shoenberger, M.D.

Jan M. Shoenberger, M.DA month has passed since we said goodbye to another class of residents from our EM training program. Their graduation was bittersweet as always. Saying goodbye to 18 fantastic residents that you have gotten to know well is hard, but at the same time you feel happy and proud that you have been a part of their professional development. This month, as we are adjusting to new residents , I think of the recent grads out there working in their new jobs and I wonder how they are doing. Are they encountering things they weren’t prepared for? Are they finding themselves in tough situations that we never talked about in their training?

I’m 100% sure that they are. It wouldn’t be a surprise. And that’s because of the disconnect between residency training in academic medical centers and community practice. In our residency training program, we often find ourselves teaching residents about how things will be in the “real world” when they graduate, as if we’re currently in some alternate universe like a cartoon world or something. But in many ways, at an academic medical center, we are in an alternate universe. Let me give you an example.

When EM residents in our hospital call a consultant for a patient, they have access to every specialty known to man. Many of the specialists are in-house 24 hours a day. They will see any patient anytime. They often will see a patient immediately just because it’s an interesting case. There is no discussion of insurance coverage or method of payment. In fact, you never even think about what type of insurance your patient has. Ever. Does this reflect the “real world” EM practice that the new grads are now working in? Or is this some type of bizarro utopian universe?

This just isn’t how it happens in the “real world”. The EM faculty members know this. Most of us have worked in the real world at one time or another. We struggle with how to prepare the residents for their eventual “real world” EM practices when we know that they are entering a specialty faced with shrinking call panels and major access to care issues. When they call the neurosurgical resident in the middle of the night for the intubated patient with a huge intracranial hemorrhage, the patient gets seen immediately and whisked away to the operating room or a neurosurgical ICU bed (if there are any open beds...a whole different conversation). I often say to the residents, “you realize, when you go out and work in the real world you may not have a neurosurgeon on your call panel.” I tell them the stories I hear from grads working at our surrounding community hospital ER’s who are faced with critically ill patients who need specialists emergently and can’t get them. They tell me about talking to those families and explaining that their loved one is dying and needs a cardiothoracic surgeon to fix their aortic dissection and they are working on finding an accepting hospital. They feel powerless in those situations and they feel unprepared. How do you prepare someone for that reality? Start them on anti-depressant therapy before they graduate? Tell them that hopefully President Obama will fix everything? I don’t know the answer but I do know that the disconnect between residency training environments and “real world” practice is just one of the reasons that EM education is a real challenge.

Comments

[susan stone]

This is just too true. How can you possibly relate to a new resident how frustrating it is to not be able to get a specialist that you need in the very place you should be able to have access...after all it is the "emergency" department. I remember working out in the community thinking I was ready until I called a cardiologist whose patient came in with cardiogenic shock he essentially used words my mother told me not to use and to not bother him. Now the hospitalists admit patients and hopefully you have some information on the history. The patient may have been followed at another hospital and you can't pull up records. The nice thing about the academic environment is that you don't have to ask about insurance and you can admit a patient if you feel it is needed-but soon even our county hospitals will have their day when they are at the breaking point.
Maybe we should simply be straight up with the residents, not sugar coat the truth and encourage them to support their specialty organization to improve care.

[Graham Gardner]

I was trained and work in the UK where most emergency patients are seen outside of the all-singing multispecialty hospital. As part of training we spend some time in such institutions but also rotate to district general hospitals which may have a much more limited set of specialties (eg no neurosurgery, cardiothoracic surgery, burns unit). I think this gives a balanced view of 'real life' and certainly helps you to develop good problems solving skills not only clinically but managerially and administratively. Is this something that happens in US ED training and could it be helpful?

[Sue Ieraci]

Similar system in Australia - it is compulsory to spend a period of your specialty training outside your core teaching hospital. This teaches trainees that there are parctice settings outside their major institution. Various types of hospitals have accreditation for different lengths of training time, according to hospital type, casemix and availability of consultant teaching staff.

[Maureen Gibbons, MD]

I think, on my part, at least, this was
expected. We really didn't think the
neurosurgeon was going to be sitting
by his iPhone waiting for us to call
from Podunk hospital- did we?

I just ask lots of questions- being the
'boss' to me doesn't mean I know
all the answers. It just means I have
a bigger hand and responsibility to do
what's right for the patient.

[Rich Paula, MD]

Gibbons, the fact that you are now the boss is evidence enough that the "real" world is a scary place.