Feb 6, 2009

Want to get into a great residency program?

If you're reading this, you probably think improving the quality of health care is pretty important. Here's someone who agrees with you:

Joel Katz is Assistant Professor of Medicine at Harvard Medical School and director of the Medicine Residency at Brigham & Women's Hospital -- one of the finest hospitals in the U.S.

When he's selecting residents, Dr. Katz looks for students who are interested in improving the quality of health care. In his own words:

The principal mission of the residency is to train great doctors -- "great" meaning doctors who can recognize who is and is not sick, act decisively in the absence of a complete data set, think critically about the 'big picture' of health and disease, and know their limits and feel comfortable seeking the advice and wisdom of their peers.

At the Brigham, Dr. Katz has recently launched a residency track in management leadership skills, including those directly relevant to patient safety and quality improvement.

Dr. Katz will be checking this blog between now and February 24. Leave a comment or a question for him here, and he'll see it. Ask anything you want. Curious about why most professional training programs don't emphasize the improvement of care? Want to know how you can make patients safer? Hoping for some tips on how to stand out in your field?

To ask a question, click the "Comments" link at the bottom of this post.


Joel said...

Hello everyone. I was kindly invited to be the February guest-host of the Open School section of the IHI web blog, which will hopefully allow me to meet students and other HCW interested in QI, safety and integrating them into the fabric of medical education (my gig). I just took my first perusal today, there aren't any comments to respond to, yet. What's more, the lead-in article refers to “prima donna's” and an article titled "Arrogant, Abusive and Disruptive--and a Doctor". How did they know? What did I do wrong? Is this me?

Please make my guest month fun by sending in your questions and ideas on any topic/concern. If I don’t hear from you, I will start sending the questions (which is a professional hazard).

--Joel T. Katz, MD

Adam said...

Thinking about the large picture and desiring to make a change often requires enthusiasm, idealism, and...time, all of which drop as you get older and deeper into your medical training. What are some ways we can remain optimistic about making large-scale changes on patient safety as our schedules become more and more demanding and we are barely keeping up with schoolwork/clerkships/residency hours?

Emory said...

On a smaller scale, what are some things medical students should do while in the wards that can help improve patient safety?

Joel said...

***Adam's great question is on sustaining optimism, and the role of time management skills.

First of all, I would say that there are very few fields that offer more promise to positively impact the world than medicine. Once trained and independent, you can directly impact your fellow citizens through the provision of compassionate and high-quality care (in medicine, surgery, pediatrics, psychiatry, pathology, etc), as part of a team. Furthermore, as a physician, you will be in an ideal position to tackle larger and more difficult problems (e.g., health disparities, access to care) as a team leader or scholar. To get there, I suggest the following: (1) find an area of medicine that you are passionate about (e.g., medical education, in my case), and seek out new experiences and higher levels of responsibility within that area (e.g., summer research, community volunteerism); (2) learn when and how to selectively say "no" -- some of the most effective leaders I know are ones who know how and when to decline opportunities (in favor of more depth in a limited area); and (3) ALWAYS stay focused on what is best for the patient -- a guidepost that will never mislead you. While the training period is exceptionally busy, as you say, is also an amazing opportunity to experience the transformative power of medicine, which is what keeps me very, very optimistic. I have seen so many amazing advances in medical care in my short career that it is very hard not to feel a palpable sense of pride and promise.

***Relative to Emory's question, my advice would be to avoid the temptation to succumb to conformity and complacency. Think about safety (in its broadest context) in caring for every single patient, on every service, and don't be afraid to mention this on rounds. For example, when caring for a surgical patient, you need to read about and know the history, the procedure and the anticipated complications. But you should also be aware of the vulnerabilities for that particular patient -- do they have enough money to take their prescribed antibiotics? can they make it to the scheduled appointments? do they understand the written post-discharge instructions? is their primary care provider fully engaged in and informed about follow-up plans. Sometimes helping solidify these aspects are as important at the operation itself (and will be greatly appreciated by the team). Also, read up on patient safety literature on rounds, and occasionally bring in such a article that may be relevant to the case at hand. Your team will appreciate it (and it may start to change practice).

***Finally, editors note: Two very nice articles worth reading in this week’s New England Journal – one on safety (food-borne infections by DG Maki) and one on HIV (stem-cell transplantation and viral control by G Hutter).

--Joel T. Katz, MD

Eva said...

Thank you for your comments and answers, Dr. Katz! It is both refreshing and promising to know that there are residency directors out there who value quality improvement and patient safety. Looking from the other side of the matching process, what should we be looking for in a residency program? What are signs or hints that a residency program is being fostered by a culture of safety?

athc23 said...

Hi Dr. Katz, thanks for taking our questions and being so encouraging! I'm a first year student, interested in subjects like epidemiology, preventive medicine, public health, and infectious disease. Upon learning this, a lot of my fellow classmates and colleagues tell me that my concern for whether a patient has appropriate support at home, how their culture might view a specific treatment, and whether their eating habits will detract from their outcomes, would better suit me to be a social worker. How do you think I should reply to these comments?

Joel said...

Thanks for your excellent questions.

***Dear Eva: Safety is a core attribute of patient care, and thereby professionalism. In the hierarchy of responsibilities, some program directors may have this higher or lower on their "to do" list, but I suspect that most if not all PD's want to support such efforts among their trainees.

Regarding your question, once you have decided what field to specialize in, what should one look for in a residency program? Some of the features that I think are worth considering are: diversity of the clinical experience (This is your chance to see a bit of everything.); teaching commitment of the Department and Faculty (Do they have interest in and time for teaching?); availability and openness of the program leadership (Are they in touch with and responsive to the residents' concerns?); and trainee morale (Are residents happy, and for reasons that are relevant to you -- i.e., contributing to systems improvement, or learning?). Secondary issues include location, access to roll models and availability of fellowships in your area of interest. There are many wonderful residency programs, and your job is to find the right fit. Meeting with residents informally is key to getting a good picture of the pro's and con's of every program. Visiting clerkships can also provide valuable glimpses into a program.

***Dear Athc23: Nothing could be further from the truth. A great doctor is one who addresses every aspect of patients' needs. I recall that one of my co-interns (20 years ago) presented a case on morning rounds of a man with a recurrent asthma exacerbation because of many factors including that he could not afford the prescription that he was sent home on. The co-intern’s conclusion, much to the surprise of the team on bed-side rounds, was that this young man was "suffering the consequences of poverty". He, of course, was absolutely right, but most of us felt completely ill-equipped to address the social factors influencing poverty -- rather we felt much more skilled prescribing beta-agonists. My co-intern's name is Paul Farmer, and he has applied this appreciation for the "big picture" (as you seem to have, as well) to improving health and medical care on a grand scale. You do not need to reply, simply keep up the good/broad thinking on behalf of yoru patients.

--Joel T. Katz, MD

Joel said...

....and one more reading suggestion in today's Journal of the American Medical Associatin (JAMA):

Shojana, et al. Clinicians in Quality Improvement -- A new career pathway in academic medicine. JAMA 2009;301:766-8.

Presents a very nice roadmap for creating a satisfying academic career in QI, written by someone who has forged the way.

Joel T. Katz, MD