American College of Physicians: Internal Medicine — Doctors for Adults ®

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Just do it: testing the waters of private practice

From the January 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine Wiebe

Just a few months into his residency, Kevin Lewis, MD, was becoming jaded about internal medicine. He was convinced the specialty involved only hospitalized patients with "hundreds of problems needing hundreds of medications." Then he began a month-long rotation in a private practice. Afterward, he saw the specialty in a much different light.

"In residency, you forget that there are people who just want to have annual exams done," says Dr. Lewis, an intern at the University of Nebraska Medical Center in Omaha. By observing a physician with 20 years in practice, Dr. Lewis witnessed a more positive, rewarding side of medicine.

"It encouraged me about the strength of physician-patient relationships," he says.

Dr. Lewis' private practice rotation is part of a new wave of community-based teaching, an effort to show residents and medical students what the real practice world is like. Specialty leaders enthusiastically say that such experiences will not only provide better training, but also will make the specialty more attractive to medical trainees. In addition, community-based teaching provides a critical link between the worlds of academia and practice, allowing private physicians to share their experience while residents offer new ideas and knowledge of the latest medical advances.

Community-based teaching is also part of a larger effort to increase ambulatory training, focusing on practice outside of the hospital. Program leaders report the experiences have been generally positive. However, not all residents have access to such rotations. According to the National Study of Internal Medicine Manpower, residents spent about one-third of their time in ambulatory care rotation during 1994-95. However, only about 15% of that time was spent in private offices or clinics with the bulk spent in hospital-based clinics.

In March 1994, the College launched its Community Based Teaching Project to develop resources for training programs, including a database of current offerings and materials to develop new ones. Much of the current activity is at medical schools, but residency programs are also getting involved (see box).

"For the most part, people accept that from an educational standpoint this is a positive thing," says Susan Deutsch, FACP, the College's project director.

A better view

For his part, Dr. Lewis says his private practice rotation was a welcome change from his hospital duties. "Not that your days are necessarily shorter," he says, "but you're shielded a little bit from all the pressures." Because he was not the primary physician, "it was a relief to be able to step back and observe how someone else would take care of a patient." The experience helped rid him of some of his biases about patients, he says, and it allowed him to re-evaluate his own practice style.

"At the same time, it was a little frustrating to be a resident and feel like you were thrust back into a medical student role," he says.

Overall, however, the experience gave him a much better view of an internist's professional life, Dr. Lewis says. In the hospital, he was accustomed to seeing patients frequently and responding often to calls from nurses.

"In the private world, I found it interesting that you only saw the patients once a day, and the support staff was much more self-sufficient," he says. In private practice, consultants respond much more quickly and collaborate more freely, he observed. In addition, it surprised him how much the phone served as communication with consultants and patients. "The efficiency of outpatient care is one of the big lessons I learned," he concludes.

Dr. Lewis rates his experience as "extremely important" and something that all residents should undergo--preferably early in residency while they are still open to new ideas.

"It definitely changed my perception of what internal medicine is all about," he says.

Practitioners who have become involved in community-based teaching also praise this new learning venue. Students and residents often are amazed to see an internist treat 20 patients with multi-system problems in one afternoon, says Gary Reiter, FACP, an internist practicing in Holyoke, Mass. "It also gives them an opportunity to see what our strategies are for dealing with difficult issues" such as nursing home placements and dissatisfied patients, he adds.

Some practitioners are reluctant to participate because teaching takes time, Dr. Reiter says. "The challenge is that if you have a busy internist seeing a patient every 15 minutes, it's hard for them to tie up a room with a student," he says.

Special techniques such as those outlined in the ACP resource materials help keep the teaching process from interfering with practice flow, says Paul F. Speckart, FACP, a San Diego internist who teaches students and residents. The pressures of managed-care contracts force physicians to work quickly, leaving little time to stand around discussing patients, he says. Instead, he asks residents to jot down areas of interest while seeing patients and then discusses those topics over lunch or after work. (For more tips, see "Help! There's a medical student in my office," October 1995 ACP Observer, p. 7.)

In fact, practitioners can benefit from these teaching arrangements, Dr. Speckart says. He recalls asking a colleague to "adopt" one of his students because he had another commitment. Although his colleague, a busy cardiologist, was somewhat skeptical, he agreed to help. Dr. Speckart returned expecting to be chided for the inconvenience. Instead his colleague told him he had forgotten how much fun it was to teach.

"The day-to-day practice of medicine has taken on some grimness with managed care," Dr. Speckart says, "and this is one way of adding some fun to it."

Tailor-made rotations

Community experiences vary greatly, from the purely observational to the highly participatory, depending on the resident's level of training and the type of practice. For instance, residents assigned to internist Frank Kieliszek, FACP, in Norway, Maine, become fully immersed in the practice. "The residents actually make our life easier," he says. Furthermore, they stimulate the practitioners because their training is "hot off the presses."

In return, residents are exposed to a much different kind of practice than that of the academic medical center, Dr. Kieliszek adds. The five internists in his group are the only ones in town, and there are no subspecialists. Thus, they practice a broad range of medicine, and residents get to see how the various aspects of internal medicine can be brought together.

Residents can tailor their community experiences somewhat by telling their preceptors what areas they are interested in, Dr. Kieliszek advises. Some of his residents have been most interested in the nuts and bolts of practice--even spending time with the business manager--while others have shown more interest in understanding a broad range of medicine, he says.

In general, residents should bone up on their physical exam skills before starting a community practice rotation, Dr. Kieliszek advises. Also, they should be prepared for a role change from that of the primary physician to more of an observer or assistant.

Residents who do not have the option of a private practice experience may try simulating a practice rotation at a hospital clinic, advises Cary Dash, MD, chief resident at Baystate Medical Center in Springfield, Mass. Dr. Dash suggests residents request adequate nursing help; then try to schedule patients at 20-minute intervals. That experience will give the residents a taste of the pace and volume of a private practice, he says.

Dr. Dash spends one day a week at a private practice and much of the rest of his time at a hospital clinic. Although the patient populations are different, he says, the main difference between the two settings is the level of efficiency. "You learn to manage your time in a different way [in a private practice]," he says.

And he is glad to have received both kinds of experience. "I've learned good medicine at the hospital clinic," he says, "but I learned efficiency at the private practice." With that combination, he feels well prepared to eventually enter the "real world" of private practice.

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

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