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Do teaching hospitals still teach?
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I recently returned to academic practice after a 12-year hiatus working in the pharmaceutical industry. I found much has changed.
When I was last in practice, the physician team was composed of an attending physician, a pediatric hematology/oncology fellow and four first- or second-year residents. At that time, a major focus was on teaching: the fellow teaching the resident the nuts and bolts of managing the complications of chemotherapy, the workup for a new patient suspected to have or recently diagnosed with cancer, and the dos and don’ts of chemotherapy administration. The attending often provided instruction on some of the bigger-picture topics, such as background on chemotherapy, risk assessment and treatment assignment, while at all times keeping an eye on the individual treatment courses of the patients.
All of this reminds me of a comment made by the chief of service, Dr. Lawrence Finberg, at Kings County Hospital, a public hospital in Brooklyn, N.Y., where I did my residency. An applicant to the residency asked Dr. Finberg if it ever worried him to be responsible for such a large service. He said (and I paraphrase) “I don’t worry about the patients. I worry about the residents. If I take care of the residents, they will take care of the patients.”
To this day, I’ve never been better able to describe a teaching hospital functioning at its best.
Fewer residents
Things have changed. There is still an attending and a fellow. Now we have one or maybe two residents on the service. Every fourth day they go home early in the morning because they have been on-call the night before. On days in which they have outpatient clinic, they do not come to the floor at all. The remainder of the service is covered by a rotating team of nurse practitioners. The result is, some weeks, there may only be a resident for 3 of the 5 weekdays.
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The pediatric resident is the outlier. That resident may be the only person on the team who does not know how to manage fever and neutropenia. The fellow or the attending can help her (or him) write the orders for the workup and the antibiotics. Afterward, there may be time to have a one-on-one discussion. If both the fellow and the attending participate, the group is now three.
Whereas once students of one stripe or another were the overwhelming majority, they are now the minority, sometime a minority of one. Not only that, being the only one in the group for whom this is not second nature, they can be a silent minority.
Nurse practitioners
Our service is fortunate in that our nurse practitioners are excellent. They are experienced, knowledgeable, caring, compassionate, and they have a great sense of humor and are fun to work with. They are receptive to teaching and interested in continuing education and improvement. They know much of the core curriculum that we consider the mainstay of the hematology/oncology experience for pediatric residents. Discussions of the management of fever and neutropenia, tumor lysis, risk adjusted therapy for acute lymphoblastic leukemia, and the management and side effects of chemotherapy have been a part of their professional lives for many years. Simply put, they require less supervision than the residents.
Integrating nurses and residents
As we restrict resident working hours and increasingly rely on nurse practitioners and hospitalists, do we lose something in the exchange?
There are many ways to bring the teams together. Conduct teaching rounds as if the entire team was made up of residents. There is a risk of boring the nurse practitioners with information they already know, but reiteration can be a good thing.
Every day after rounds (on those days when the resident is not post-call or in clinic), the attending can take 20 or 30 minutes and teach on any number of subjects. Some days, there will be a patient management issue that will provide the teachable moment. On other days, fill in the gaps with the core discussions about differential diagnosis, the diagnostic workup or clinical research methods.
Ideally, a teaching hospital is an environment in which education is so intertwined with patient care that when one suffers, they both suffer. A teaching hospital is the place where on those very good days, learning leads to superlative patient care and provides for the next generation of inspired physicians.
Michael N. Needle, MD, practices at the Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University Medical Center.