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A potential cardiac arrest, a breast cancer survivor managing her pain and a patient seeking help for her depression-not a typical hour in the workday for most people. But it is just the start of a shift for third-year medical resident Daniel Lachant at the University of Rochester.
Lachant is among nine residents working one of three shifts to ensure round-the-clock coverage at the Strong Internal Medical practice. The clinic is on the fifth floor of the ambulatory care unit at Strong Memorial Hospital. It serves the community by taking new patients, which doctors say many practices can no longer do, and it serves the university by providing training for interns and residents.
"The residency here does a great job in letting us make the decisions as we progress," says Lachant, who came here from St. Joseph's University in Philadelphia. "We have the attending physician to present to and discuss our ideas. They are there to fall back on as we are learning."
Education is a key component of every shift. Residents are matched with experienced attending physicians who oversee their work and consult with them. Rochester's reputation for a higher level of engagement and an enriching education is what brings many to the residency program, URMC leaders say.
To get a better understanding of a residency program, its demands and its ability to bring new doctors to the area, the Rochester Business Journal followed Lachant on one of his shifts last month.
Learning on the job
Each day begins in a conference with two residents who present a patient report with diagnoses. There also are brief demonstrations by attending physicians, such as one on shoulder injury that occurred before Lachant's shift started and he was called to the emergency room to monitor the patient at risk of cardiac arrest.
"You can read a textbook, but it's not until you see it in real life that you fully understand how it impacts real people," Lachant says. "It can be insightful when a family member comes with the patient on their visit."
Since the clinic appointments are scheduled just 30 minutes apart, Lachant does not have much time to gather information about his patients during their visits. He has learned to pick up cues in various ways, including from accompanying family members. A patient may say she is sleeping or eating well, but her companion may tell a different story.
In some cases, the patients do not speak English very well. That is the case with another patient on Lachant's current shift, a Spanish-speaking woman complaining of chronic back and leg pain. An interpreter translates and relays the patient's concerns to Lachant as he keeps his eyes on the patient.
The thoughtful, compassionate manner Lachant displays is not likely something that can be taught, but it is certainly encouraged by the leaders he interacts with every day.
"We try to make this experience as much like the patient-centered model as possible. We want to have a humanitarian approach," says Marc Berliant M.D., division chief of internal medicine and the attending physician overseeing Lachant.
To ensure that residents get a well-rounded education, a diverse staff of professionals is on hand at the practice, he explains. That includes social workers, a pharmacist and even a dietitian, in addition to the primary care physicians overseeing the residents.
They all work from a central location known as the workroom. It has computer terminals, shelves lined with medical reference guides and miniature models of various skeletal and muscle parts, and walls with charts showing proper patient visit guidelines.
Renee Dallasen says she has enjoyed her residency in Rochester so much that she hopes to extend her stay through a cardiology fellowship, which would mean three more years of education, hands-on training, with a salary of about one-third what she might earn once she is in private practice. A third-year resident, Dallesen moved to Rochester after completing medical school at the University of Pittsburgh.
"My experience at URMC has definitely helped me to become a stronger clinician. I believe that URMC places a great deal of emphasis on providing excellent clinical care," she says.
"I have learned about the management of a multitude of illnesses. By taking on the role of team leader on medicine wards, I have also learned how to delegate tasks while continuing to provide great care to patients."
The main role of a resident varies with the specialty and level of training. The focus for the residents in internal medicine is to serve as primary care providers for patients who have been admitted to the hospital with general medical problems. The first-year trainees, called interns, serve as the primary providers, while the upper-level residents function as team leaders.
The residents make rounds daily as a team to review overnight data and changes in clinical status, and they come up with a plan for each medical problem. They communicate with family members, outpatient care providers and specialists and others in the hospital, such as nursing staff, physical therapists and social workers, to get the whole picture.
They also have outpatient clinics where they serve as the primary care providers for patients who are not in the hospital. On this shift, Lachant is working with a new admission.
After meeting the patient, Lachant consults with Berliant. He makes his recommendation for the patient's course of treatment, and Berliant agrees. Lachant returns to the patient to review the decision with her.
"Half of what we do here is psychiatry, and the patients come to us because they have to wait so long to see their doctor for their meds," Berliant says. "It's part of the reason we have a pharmacist with us now. But it all adds to how much more a resident has to learn, is expected to know, as part of his job in internal medicine."
Such responsibility can be daunting for inexperienced residents. On the one hand, they want to grow into their professional independence and earn the respect of their peers, but at the same time it can be unnerving to stand completely on their own.
"The level of respect and 'protection' that we in the internal medicine program receive from our administration is superb," says Christopher Montgomery, a third-year resident from Tufts University.
He adds: "I cannot emphasize enough how supportive our program is. That is actually one of the reasons I chose to come to the U of R and Strong Memorial Hospital in the first place."
Staying in Rochester
Montgomery has accepted a position to stay on as one of the chief residents in the internal medicine department next year. His decision to stay is the one program leaders hope many residents will make once they complete their residency.
"Forty percent of our residents stay in Rochester," says Mark Taubman M.D., dean of the UR School of Medicine and Dentistry. "For a private school, getting 40 percent to stay in Rochester is exceptional. And many of our residents go on to positions of leadership, here and across the country."
Rochester competes for residents with larger cities such as Boston and San Francisco, Taubman says, because younger, single students may want the big-city life. The main draw for Rochester, he believes, is the quality of the program.
"We have an excellent reputation for our education, even to the point of being designated as a special program to do some experimenting with things such as conditions on how people rotate through the night," Taubman says. "Most of our residents come from top medical schools. A third comes from New York State. We tend to be regional."
Making the program as attractive as possible so residents will choose Rochester is part of the strategy to attract more general practitioners here.
"If we can get them on a plane and get them here, they like it here," says Diane Hartman M.D., senior associate dean of graduate medical education. "They don't feel abused. We look at our work hours closely. We do it with the intention of teaching them to be good physicians."
There are many lucrative fields of specialization in medicine, but there is a need for family practice physicians, pediatricians and cardiologists here.
For as much work as Lachant's residency has been-there is no typical schedule, and he works an average of 60 to 70 hours a week-he hopes to continue with more work and study in Rochester.
"If I graduate I would be an attending physician, and I would apply to see if I could get a faculty position here," he says. "Four of the five residents who graduated last year here are now attending in the hospital here."
There are personal reasons for wanting to make Rochester his home: His significant other is here now. But Lachant says he has had many rewarding experiences in his work as well.
"It helps you grow as a person and as a physician," Lachant explains. "You see people at their most vulnerable position. Other times it's a great experience because you can fix somebody's problem and send them home."
The son of a New Jersey physician could have chosen a completely different career path, however.
"I was a rower in college, and I could have trained for the Olympics," he says. "But instead I decided to go to medical school. ... I have never regretted my decision. I truly love medicine."
Lori Gable is a Rochester-area freelance writer.
11/8/13 (c) 2013 Rochester Business Journal. To obtain permission to reprint this article, call 585-546-8303 or email firstname.lastname@example.org.