Dr. Wiese said an easy way to question the validity of one ACGME rule is to examine the guideline that limits a first-year resident’s census to 10 patients. He wondered which scenario offers more teaching opportunities: a roster of six chest-pain cases, two pneumonia cases, and two similarly familiar or relatively safe cases, or a resident with only four cases but each one having multiple comorbidities and complex decisions?
The new rules provide hospitals and HM groups an opportunity to change their way of thinking, adds Jeffrey Schnipper, MD, MPH, FHM, of Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. “Every program has to change its entire way of doing business anyway, so let’s be at the table and say, ‘Well, while you’re redesigning your entire program, let’s inject patent safety and quality of care, and good pedagogy into the system,’” he says.
CLINICAL
Skin is In: Dermatological Images Every Hospitalist Should Recognize
MODERATOR: Paul Aronowitz, MD, FACP, internal medicine residency program director, California Pacific Medical Center, San Francisco
A patient comes into the ED with a blistering skin condition, but the diagnosis escapes the triage doctor on the case. The problem turns out to be bullosis diabeticorum, but the ED doc doesn’t know that yet and pushes to add a patient to the upstairs HM roster.
“The ED will usually try to admit because they’re worried [the patient has] some terrible drug eruption, but they can actually go home,” Dr. Aronowitz explained. “Hospitalists can help tell the difference.”
HM groups shouldn’t work to become amateur dermatologists, Dr. Aronowitz added. However, given that many hospitalists find themselves confronted by dermatologic cases several times a month, a rudimentary pedigree is a good idea to help sift out which cases require admission and which would take up bed space required for others.
He referred to it as knowing enough to know whether you know enough. “For sure, a hospitalist can diagnose a hypersensitivity reaction from a classic drug like Dilantin,” Dr. Aronowitz said, “and then stop the drug, because that would be one of the best things they could do.”
The session exposed hospitalists to dozens of images of skin conditions theymight come across in daily rounds, from snakebites to drug reactions to argyria.
“The idea is to help hospitalists recognize what’s serious and what’s not,” he said. “If you recognize those initial cutaneous clues, you can guide your antibiotic therapy, or whether you need antibiotics.”
CAREER
This Disease Is Easy; It’s the Patient Who’s Difficult
Speaker: Susan Block, chair, Department of Psychosocial Oncology and Palliative Care at Dana Farber Cancer Institute, Boston
Every physician will have their “button pushed” by a patient now and then, and hospitalists are in the unfortunate position of having little or no previous relationship with most patients, according to Dr. Block, a national expert in physician-patient conflict resolution who said “interpersonal challenges are an onerous part” of the job.
“We want to make sure we provide really good care to these patients, but it can be very challenging,” she said, noting that between 10% and 30% of patients in the healthcare setting present with difficult behaviors.
Whether it’s an empowered patient, a traumatized patient, an intrusive family member, or a patient with clear psychosocial issues, Dr. Block explained that “these patients can make physicians feel lousy. … Being aware of that and trying to stop that process is one of the key issues in professionalism and competence in working with difficult patients.”