By 7:15 on a recent Monday morning, intern Loida Viera, M.D., and second-year resident Charles Dela Cruz, M.D., have been working for 24 hours straight in YNHH’s new Acute Care for the Elderly (ACE) unit. Viera admitted six patients to the unit during the night, and she and Dela Cruz are preparing for “work rounds,” during which they will convey all they know about the new patients to their counterparts on their residency team, intern Robert Bercovitch, M.D., and second-year resident Francis Chan, M.D. Medical student Robert McGlynn will join them.
Along with attending physician Leo M. Cooney Jr., M.D. ’69, Humana Foundation Professor of Geriatric Medicine, the five move in a tight pack through the hallways before coming to rest in the hall outside the room of a newly admitted patient. By tradition, interns present cases, and Viera, a freshly minted graduate of Tulane University School of Medicine, betrays no fatigue or uncertainty as she fashions clipped, efficient clinical narratives from the blizzard of acronyms, abbreviations and numerals that are the lingua franca of modern medicine.
The truism that today’s patients are far sicker than those under residents’ care 30 years ago is nowhere more true than in Cooney’s ACE unit. As Viera presents updates on the unit’s more familiar cases, Chan and Bercovitch must keep track of multiple diagnoses, a litany of test results and combinations of several medications for each patient as they prepare for their shift.
By 9 a.m., the handoff is complete, and Dela Cruz and Chan are free to attend residents’ report, an informal one-hour exchange of ideas among the chief resident, attending physicians and house staff, while Bercovitch keeps an eye on patients in the ACE unit. Meanwhile, Viera huddles in front of a computer screen in a small ACE workroom with McGlynn, using the six postcall hours that remain under Accreditation Council for Graduate Medical Education (ACGME) rules to complete paperwork and order tests and medications for her patients.
At 11 a.m., the four residents and interns are reunited for attending rounds, where Cooney compresses more than 30 years of clinical wisdom into a one-hour lecture based on cases of interest in the unit. Today’s topics: gout and pressure sores, two banes of geriatric medicine. Cooney seamlessly weaves anecdotes from his hospital experiences and his days as a volunteer physician at a homeless shelter together with précis of recent articles on molecular medicine, and delivers the whole package with warmth and humor.
After a thorough review of Viera’s notes, Dela Cruz attends a lunch conference and leaves at 1 p.m. On those days when her notes are complete, Viera leaves at noon. She may opt to spend her lunch hour at Fitkin Amphitheater, where a changing cast of faculty present intern-friendly lectures on various clinical concepts.
Viera will return at 7:15 the following morning, but for now Chan and Bercovitch have taken the reins.
For Asghar Rastegar, M.D., professor of medicine (nephrology) and associate chair for academic affairs, the key to preserving professionalism and a commitment to patient care under the new rules lies in a “cultural shift”: residents must be convinced, he says, that patients’ interests will be best served when they scrupulously watch out for their teammates. He and his colleagues have taken pains to see that the handoff process is not only thorough, but sufficiently reassuring for dedicated residents to go off duty with a clear conscience.
“It only works if you know that the team behind you is going to do everything possible to take care of the patient and take care of you, and if they know that you will do the same thing,” Rastegar says. “That you cannot write on a piece of paper.”