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Ticking Clocks: Reflections on Maria Maldonado’s Narrative Matters Essay



September 9th, 2013
by P. Preston Reynolds

I have wondered for nearly 25 years — since the day I started residency at Johns Hopkins Hospital — why the sickest patients with the most complicated social conditions are often cared for by the least trained physicians in American medicine. I still ponder this reality in my current role as an attending physician in a faculty-resident hospital-based clinic where we see predominantly uninsured and underinsured persons.

In the August Health Affairs Narrative Matters essay, Dr. Maria Maldonado, head of the internal medicine residency program at Stamford Hospital, and her resident battle time constraints in a safety net clinic to save a patient’s life.  Maldonado’s essay raises several critical issues, including the continued segregation of the uninsured and underinsured into safety-net and resident teaching clinics, the critical need for time and additional resources to care for these patients well, and the necessity of modeling the skills of professionalism and clinical wisdom to residents.

Residents, fresh out of medical school, are often the front-line providers of ambulatory care to uninsured and underinsured patients. Their patients’ lives are commonly burdened with living environments that are unsafe and unstable, in homes that are shared with family members who struggle with drug abuse, mental illness, imprisonment or unemployment. Not only are residents asked to be the front-line providers for the sickest people, but they are expected to do so without adequate time and resources. The scarcity of interpreters, mental health professionals and social workers in resident clinics exacerbates an already challenging set of medical needs.

At a minimum, patients’ health outcomes are impacted, and insecurity and frustration among trainees is heightened. The problems often seem overwhelming — until the senior clinician, seasoned in communication and clinical wisdom, steps in. Attending clinicians must be mindful of the needs of both residents and patients. They must know when to take over the encounter and when to allow the resident to assume the role of doctor.

Recently, I was assigned a half-day precepting session where I supervised a group of residents in a teaching capacity, all of them with full clinic schedules. The sister of a patient, however, paged me at 7 am, worried about her brother. The ER had discharged him the night before, but his symptoms only worsened after he came home.

The more I listened, the more alarmed I became. I told her to bring him in. I figured I would see him, while also precepting residents. After talking with and examining the patient, I was convinced he had a life-threatening condition and pushed hard for his admission to the hospital. I managed this acute clinical situation in between my residents’ presentations of similarly complicated patients who also needed my full attention. They learned about my patient between discussions about their patients’ clinical and social problems. Three days later, a resident I had precepted that morning emailed me: “Dr. Reynolds — it seems like your patient was presented to morning report today. You were right on it.

Serving as an attending physician in a busy clinic demands a unique set of skills. The skills modeled by Dr. Maldonado in the accompanying essay are the backbone of medical professionalism, now required of faculty — by the Accreditation Council for Graduate Medical Education — to impart to residents as one of their core competencies.

Medical professionalism is the dedication to caring for patients with the utmost attention to detail while also communicating with patients and eliciting their understanding of their illnesses and treatments.  It is allowing patients to share their stories so they can begin to heal. It is following up on test results so that illnesses can be addressed sooner rather than later, and diseases can be cured instead of becoming fatal events. It requires us to teach junior physicians how to think through symptoms to reach a correct diagnosis, and learn how to work-up and manage patients while keeping costs to a minimum. It requires us to utilize a wide range of community resources — legal, financial, mental health, social support, and others — all to serve the best interests of patients. Embodying medical professionalism is challenging in safety-net clinics, where time and resources are precious and in short supply.

Teaching Health Centers. The Affordable Care Act authorized $230 million for a new program, the Teaching Health Center Graduate Medical Education Program, which provides funding for residency training in Federally Qualified Health Centers (FQHC). Now in its third year, the program has awarded funds to 44 FQHCs in 21 states., enabling these centers to establish or expand training programs for residents in family and internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and general and pediatric dentistry. In the most recent funding announcement, Health and Human Services Secretary Kathleen Sebelius stated that more than 300 residents will be trained through this program during the 2013-2014 academic year, doubling the number of residents trained in the previous academic year.

As a resident, I had my weekly ambulatory clinic in a FQHC and came to value highly the guidance provided to me by more senior clinicians. Perhaps that is why I have chosen to care for patients in a safety-net clinic and why I remain committed to modeling professionalism and clinical wisdom to my trainees. Both require time, often more time than we’ve got in an afternoon, a day, or even an entire residency. But if we fail to take time, our patients, our future physicians, and American medicine will pay the price.

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