Clinic experience for fellows: skewed toward specialization?

Frustrating experience in the brief weekly exposures to outpatient clinic setting can lead fellows to choose procedural subspecialty.

A well-rounded training program must balance the rigors of managing acutely decompensating patients and providing routine inpatient care with experience in the outpatient setting. While proficiency in the management of acute myocardial infarction, tamponade, cardiogenic shock and aortic dissection comprise much of the “excitement” in clinical cardiology, the majority of the practice of cardiology is done in the office, whether in academia or private practice.

As a resident and fellow, a physician in training unknowingly assumes the role of “hospitalist” for the duration of his or her education, with brief weekly exposures to the outpatient clinic setting. For better or worse, I believe that this limited exposure dictates much of the sentiment toward outpatient medicine, which ultimately factors into specialty selection.

Little positive reinforcement

The majority of clinical training programs require residents and fellows to attend weekly clinic sessions. These clinic visits can be extremely fulfilling but also can lead to significant frustration. Some of the barriers to rewarding clinic experiences — more prevalent in training program clinics — include lack of continuity, either due to limited appointment times or loss to follow-up; language barriers that may require significant delays while awaiting a translator; lack of insight or motivation from patients; and limited organization in medical record keeping.

Roderick Tung

I believe that one of the main reasons that people specialize is the lack of positive reinforcement from clinic experiences. In residency, my general medicine clinic was extremely rewarding overall due to relationships that developed over three years, but it was tainted by a handful of narcotic addicts who would often page me after hours for a refill of an oxycontin prescription several days before they were due for it.

I must admit that I was somewhat turned off by the overwhelming number of chronic musculoskeletal pain syndromes. It is easy as a specialist to defer the nonfocus organ complaints to other physicians, thus simplifying the relationship with the patient.

Experience can be disjointed

Many of us went into medicine for the continuity in patient care. The establishment of longitudinal trust between physician and patient can be very mutually meaningful. But the clinic experience can leave a bad taste as it is often the opposite—disjointed and disorganized.

This limited view of out patient medicine can falsely skew one’s vision of his or her future profession. I frequently hear many of my colleagues rationalize their choice for a procedural subspecialty by saying, “I would rather cath all day than sit in clinic and see one patient after another.”

I can’t offer a solution to this bias that is inherent to the medical training system, but recognition of this fact may be helpful in the decision-making process.

Roderick Tung, MD, a fellow at Cedars-Sinai, joined the Cardiology Today Fellows Advisory Board in November 2005.