New interns are here! This is obviously the biggest news of the season. Welcome to the newest members of our residency family. The intern class has now been in Denver for just about a month and are settling in to life in a new locale (for most) and new professional (for all). By all accounts they are doing so in wonderful fashion (see Accolades and Accomplishments, below).
Fellowship season is upon us. Program letters for fellowship are off, personal statements are being finalized and ERAS opened on Monday. We have 32 senior residents and immediate past graduates applying for fellowship this year. Having the opportunity to write a letter (along with much help from Nicole Goodwin and the Associate Program Directors) allowed me a chance to really look at who is coming out of this program. It should come as no surprise to anyone that I was blown away by the character of our residents, let alone the heft of their CVs and applications. Last year we placed > 95% of our residents in a program within one of their top three choices, including in all the most competitive fellowships. I expect it will be another big year for the program in 2018-2019. Good luck to all our fellowship applicants!
RPEC is starting to bear fruit: I’m pleased to announce that the results from Resident Program Evaluation Committee (RPEC) review of the VA Wards are in. Starting with this edition of the Residency Update, look for the new RPEC Output section to see what you as a group think of a particular rotation, what suggestions you made for improving it and how the program responded. The RPEC will always take a break for summer but will be back up and running in September and will review 10 rotations or aspects of the program annually. Interns, if this is something you are interested in (improving the program from within), keep your eye out for these monthly events. Keep reading to see what changes are coming/have already started at the VA. Next month: UCH MICU.
The residency family is going to grow by one this winter. The gravity of the news is big (at least for me) even if the ultrasound I saw this week says it is very, very small. Mariah and I will welcome our first child sometime right around Christmas 2018. We’re both hoping it has its mother’s hair, along with most other heritable traits.
AMA Conley Art of Medicine and Ethics Essay Contest: The winning art entry as well as the winning ethics essay are each awarded $5,000 prizes.
Social Cohort Events: Keep your eyes out for Social Cohort activities. You’ll see these announcements from your Chief Resident. They are always a good time to get to know one another, take a break from your usual activities and explore Denver. Occurring on your +1 weeks when time is less spoken for, I encourage you all to attend as many as possible. Recently, one group got to witness the Rockies drop 19 runs on a team in a single game. Which is unheard of. Unfortunately for the boys in black, purple and silver, the superintendent of the opposing high school has vowed never to allow his team to return to Coors Field, meaning the Rockies will have to go back to playing MLB teams exclusively.
Accolades and Accomplishments
I know the interns are new and all but they are already knocking it out of the park. I got called twice this past week from nursing supervisors at UCH because they wanted to “talk to me about my interns”. I took a deep breath and called back, only to find two separate nurses who wanted to tell me that they thought our interns were fantastic. Similar to a Rockies team scoring 19, I do not get calls from nursing leadership simply to commend our people every day. You all are doing something very right.
To put a finer point on it, I want to share the following accolade that came to me this week via email. Names and places have been redacted – not because I don’t want to recognize any one person, but because I think this could have been any of you. The stories of teamwork and selflessness and brilliance that I have been hearing since June 23rd back that up. The following came from a senior resident, the salutation at the end is his/her own:
“I wanted to give my interns a shout-out, because they are operating at a level far beyond what would be expected for interns in the first two weeks of residency. They are incredibly hard workers but are somehow also incredibly efficient whilst working within an entirely new healthcare system, fearlessly trudging through the bureaucratic hurdles of (hospital with bureaucratic issues). Both also have an incredible amount of integrity that is really humbling to observe. There have been a few occasions when I've heard the usual workplace gossip transpiring and (wonderful interns) don't engage -- they raise the standard for those around them and for our program. It's quite rare to see a balance of such excellence and humility, and it has truly been an honor to work with them.
Spoiled R2/3 in Denver,”
I’m incredibly proud of this class. Keep it up.
RPEC Output – VA Edition
So the first RPEC is in the books! First, thank you to all the RPEC resident leaders who got together to help plan the structure of these evenings, ran the meetings with their classmates and then meet with me, the VA leadership and our Chiefs to come up with some workable changes to the VA structure and function. Also, thank you to Kinnear Theobald and Jackson Turbyfill for serving as the VA attending leaders. Finally, thank you to Dan Heppe and Mel Anderson for responding to the RPEC ideas and implementing real change, quickly. I think a lot of good came from this exercise with changes by the residents, for the residents.
A summary of the RPEC and its three intended discussion sections, along with the upcoming changes at the end (edited for content, there are many smaller suggestions and changes that may not make this list but that you will see on the wards):
What residents love about the VA and should not be changed:
- The patient population
- Team structure of 1 resident, two-intern teams
- The attendings and their level of engagement
- Noon conference cases
- The open ICU
- The availability of fellows during the day
- What residents wish could be changed about the VA:
- Figuring out which ancillary staff member is helping your team/your patient on any given day
- The ill-defined role of the discharge planner
- The burden of “non-medical” paperwork
- Going over cap when it is busy
- Odd distribution of admissions to the ‘regular’ and ‘early’ intern, especially when the ‘early’ intern is staying quite late
- Nowhere to offload extra admissions or long-stay patients
- How patients are scheduled into PDC
- Documentation burden
- The facilities
- OIG calling residents
What the RPEC suggested we do to fix things/what we are fixing based on your suggestions:
- Going over cap is painful: We will now set the cap at 16 touches per day, firm. A simplified admission algorithm will also be rolled out in July/August to facilitate making this as easy to accomplish as possible. In addition, Team X (keep reading).
- The PDC can be tough, especially if you don’t really know the patient: In response to this issues, changes have been made to the PDC. From now on, you are only responsible for seeing PDC patients that you actually cared for. If a patient is scheduled into the PDC who is not known to the resident team, the attending of record will see that person alone. This requires that you, as the residents, do your best not to schedule patients as you will be rotating off of service but can be implemented immediately.
- We wish we had some control of the admission pager/triaging as well as someone other than the late/early intern to help with admissions: While we have to admit this is something that we in the residency leadership and VA hospitalist leadership were thinking about for a while now, it was the RPEC voice that helped push the idea forward. As many of you know, there is a new team at the VA in 2018-2019 called Team X. The RPEC at VA next year will be focused on finding a better name for Team X. But for now, this will be a fifth team in the admission drip to help offload admissions. This should eliminate, in all but the rarest circumstances, the dreaded “supercap”. It will also be the team that holds the admission pager, thereby getting you the residents involved in the admitting and triaging as requested. New teams always require some tweaking but we hope this really helps with your workflow and experience at the VA.
- The facilities could use a lot of improvement: At great cost to the residency, we commissioned the building of an entirely new hospital, due to open next month. Never say your concerns aren’t taken seriously…
- Team structure, how to accomplish things and institutional knowledge should carry one from one month to another: We agree! And thanks to the efforts of the VA hospitalist leadership and very much thanks to Miheer Pujara, they will now. Miheer already has Verison 1.0 of the VA Wiki up and running to serve as a living document where all VA-related knowledge can live. Add the Wiki and never let a VA shortcut die on the vine again.
- Smaller but Important Changes:
- Define the role of the Discharge Planner: After this suggestions, Mel is currently working with the supervisor of the D/C planners to standardize their role and presence. We are working with an interim supervisor so change may be slow but this dialogue is open and ongoing.
- Formalization of the multidisciplinary team: A D/C checklist was developed (similar to PSL/DH) with plans to have the D/C planner run and coordinate these rounds. In addition, PT is hiring a “lead PT” who will attend multidisciplinary rounds daily to facilitate PT issues. Pharmacy will also join multidisciplinary rounds. This will be the start of a standard process with standard work for all with almost all the necessary players in the room.
- The attending should be present at multidisciplinary rounds: This is a great suggestion, only limited by time and team rounding. We will start with having the attending there 2-3 times/week to start and make changes once we see how this is received.
What I’m Reading
https://www.nejm.org/doi/full/10.1056/NEJMoa1800389: In case you needed any more proof that eating well is good for you.
https://www.nytimes.com/2018/05/21/science/mosaicism-dna-genome-cancer.html: Just when you think you know who you are, think again…
What I’m Reading When I’m not Reading Medicine
“A green hunting cap squeezed the top of the fleshy balloon of a head. The green earflaps, full of large ears and uncut hair and the fine bristles that grew in the ears themselves, stuck out on either side like turn signals indicating two directions at once. Full, pursed lips protruded beneath the bushy black moustache and, at their corners, sank into little folds filled with disapproval and potato chip crumbs. In the shadow under the green visor of the cap Ignatius J. Reilly’s supercilious blue and yellow eyes looked down upon the other people waiting under the clock at the D. H. Holmes department store…”
- John Kennedy Toole, “A Confederacy of Dunces”
This novel represents the outsized hilarity, sadness and plain old weirdness of life in New Orleans. It was conceived in the dark by an unknown amateur and only brought to light after his passing by the inspiration of Walker Percy. If you haven’t met Ignatius J. Reilly, I invite you to do so but go in prepared for an amalgam of Mark Twain and Cervantes, edited by Tom Wolfe. Optional if you’re from outside of Louisiana, a must if you’ve ever lived in or visited New Orleans for any length of time.