F E AT U R E
•
F E AT U R E
THE RESIDENT IS IN
2 On Call in Medicine with Anne Quismorio, M.D. 7 a.m. Anne Quismorio, M.D., a third-year resident in the Department of Medicine at the Keck School of Medicine, arrives at LAC+USC Medical Center, the County hospital, and grabs coffee. 7:30-8:30 a.m. She
meets her team on the floor to be briefed on the five new patients who were admitted overnight by one of the interns who was on call. The team includes one third-year resident, one second-year resident, two interns and two medical students. The attending physician, a Keck School faculty member, rounds with the team later in the morning. With 17 patients to see in total, they begin their first set of patient rounds (work rounds). Five of the 17 are in the jail ward. One patient has lung cancer that has metastasized to his brain; another has poorly controlled diabetes and is refusing dialysis. Two of the patients are being treated for drug- and alcohol-related complications. The team sees as many patients as they can within the hour. Later in the morning they will revisit these patients and see the remaining ones with the attending physician on their team, Mark Kang, M.D., M.P.H., during attending (teaching) rounds. Morning report is designed for all of the Medicine residents to meet every morning to present and discuss patient cases, though not all are able to attend every day. Typically, two residents present one patient case each to a roomful of residents and a few attending physicians. On this day, Quismorio listens to a case about a patient with endocarditis, inflammation on the inside lining of the heart chambers and heart valves. The primary goal of morning report is educational. After reviewing and analyzing the patient cases, residents receive feedback from the attending physicians about their patients’ diagnoses and treatment.
8:30-9:30 a.m.
9:30-11:30 a.m. Teaching
rounds with Mark Kang, M.D., assistant professor of medicine at the Keck School. The Medicine team gathers in a conference room to
(Continued on Page 14)
12
KECK MEDICINE | Summer 2010 Issue
3
are fearless. They absorb their whole beings into their patients and their family members. And our patients, in return, are humble and appreciative of the care they get here,” says Pete Delgado, CEO of LAC+USC. “The residents are 900 of the brightest individuals with whom we’ve been privileged to work.” Be yond the Ca ll of Du ty While residents are recruited based on their skill and capacity to learn, Delgado says it’s also important that they demonstrate cultural sensitivity and an eagerness to work with a diverse patient population. “LAC+USC is where patients go when they have nowhere else to turn. Our patients are very sick and many come in almost on their deathbed,” he says. “Our residents know this and understand the social barriers that these patients live with, and they go beyond the call of duty to care for them.” Delgado has seen residents help patients in extraordinary ways − from buying groceries for patients’ families to ensuring that patients have transportation to their doctor’s appointments. The diverse patient demographic is a big lure for some residents. “You can make a very big impact on patients’ lives here,” says Socrates Susim, M.D., a fourth-year Keck emergency medicine resident who calls himself a community doctor at heart. “The patients I see are often uninsured and of a low socio-economic scale. These are the patients I have chosen to serve. It’s good to brush up with people from different cultures,” Susim says. About 500 patients come through the Emergency Room every day, and 50 to 70 can be found in the waiting room at any given moment. Since 60 percent of LAC+USC admissions come in through the ER, Susim gets a lot of exposure to different kinds of pathology. “What you read in textbooks happens here,” Susim says. He has seen patients with fresh gunshot wounds, flesh-eating bacteria and end-stage diseases who have never been to a doctor before. He also has seen patients who’ve been in terrible motor vehicle accidents and have suffered from traumatic amputations and bad lacerations. A tremendous sense of responsibility comes with being an ER resident. “When you’re working in the ER, you’re taking care of everybody’s patients and then you hand them off. It’s an opportunity to interact and consult with all specialties,” says Stephanie Hall, M.D., assistant professor of emergency medicine and assistant dean for LAC+USC at the Keck School, chief medical officer of LAC+USC Medical Center, and a graduate of the Keck School. One challenge that many residents face is a language barrier. Since more than half of the Hispanic patient population at LAC+USC (which comprises 65 percent of the overall patient population) speaks only Spanish, most residents there have had to learn Spanish in order to communicate with these patients. “Growing up in Canada, I never learned Spanish in school, so I’ve had to learn it on the job,” says Janie Weng Grumley, M.D., a fifth-year surgical resident, who says she speaks “medical Spanish.” She has mastered the art of asking medical questions in Spanish but says that understanding the responses can be challenging. Fortunately, many of the Spanish-speaking hospital staff members are very willing to offer translation help. Residents also serve another diverse population, with whom they probably wouldn’t otherwise interact − prisoners from Los Angeles County jails. Patients are transported primarily from the nearby Twin
•
General and Laparoscopic Surgery Clinic with Janie Weng Grumley, M.D. [A full clinic day for a surgery resident begins at 8 a.m. A day in the Operating Room begins at 6 a.m.] Fifth-year Keck School of Medicine Surgery resident Janie Weng Grumley, M.D., sees a patient who says everything hurts from head to toe, but complains specifically of belly pain. Grumley sends her for an abdomen scan.
12:30 p.m.
With attending physician Mark Kang, M.D., M.P.H., right, are team members, from left, Louis Hirsch, third-year medical student; Michael Elist, M.D., intern; and Anne Quismorio, M.D., third-year resident. Kang is assistant professor of medicine in the Division of Geriatric, Hospital and General Internal Medicine at the Keck School of Medicine.
Towers Correctional Facility to the LAC+USC jail ward, which is located on the hospital’s ground floor. Access to these patients is very limited and security is tight. Police officers line the hallways of the ward and guard each of the 24 patient rooms, granting access only to physicians and those with proper identification. Prisoners suffer from a variety of health problems, including wounds suffered from violent assaults, liver disease from abusing drugs and alcohol, and other chronic health issues. The diversity of the patient population is just one of the many appealing aspects of the Keck residency experience at LAC+USC. Residents also are attracted to the structure of the program. “When you look at the larger picture of residency education, the resident is looking for that balance between supervision and autonomy,” says Lawrence Opas, M.D., associate dean for graduate medical education at the Keck School. He says the program was built to meet those expectations. As their training progresses, residents assume greater responsibility and more of a leadership role. “Even if you don’t naturally see yourself as a leader, you have to become one,” says Quismorio, who helps lead a team of five, including a second-year resident, two interns (first-year residents) and two medical students. An attending physician oversees all clinical decisions and activities. Since Quismorio is often called upon to be in more than one place at the same time, she has to delegate some of her responsibilities to other members of her team, such as writing physician’s orders (e.g., ordering a patient’s discharge from the hospital or documenting a patient’s health status) or examining a newly admitted patient. Ultimately, Quismorio will see all patients admitted on her service as she is the one who is responsible for their care. Quismorio also receives great support from the attending physicians, all of whom hold faculty appointments at the Keck School. She describes them as being very approachable and eager to teach. “It’s comforting being in training
Behind t he Scenes
1 p.m. She sees a patient who recently had gastric bypass surgery and now has gallstones in her gallbladder. Because of the previous surgery, the typical way of removing gallstones won’t work, and Grumley admits the patient to the surgical service in the hospital. 2 p.m. She sees a patient with a poking sensation pain in her abdomen. Grumley checks her abdomen and feels a small hernia. 2:30 p.m. She sees a patient with gastric cancer who suffers from episodes of advanced bleeding. Grumley confers with attending physician Ashkan Moazzez, M.D., assistant professor of surgery at the Keck School, about this case, suggesting that the patient needs a gastrectomy (surgical removal of all or part of the stomach). Moazzez agrees and goes to the examining room to discuss the risks of surgery with the patient and his family. 3 p.m. – onward. Grumley sees patients until about 4 p.m. After clinic ends, she follows up on the studies pending from her morning hospital rounds.
www.usc.edu/keck
KECK MEDICINE
13