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

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California: shaking things up

Residents get an early taste of managed care medicine

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

By Deborah Gesensway

LOS ANGELES--As Melissa Rapp, ACP Associate, interviews at group practices and HMOs around Southern California this spring for her first job, she is optimistic. She believes her residency program at Cedars-Sinai Medical Center has prepared her to work in managed care.

After all, for the past three years, although she has been based at a traditional large academic hospital, she has been working in the very different world of managed care.

She knows dermatology and is comfortable performing exercise stress tests. She has done hundreds of pelvic exams. She has dealt with utilization reviewers, knows how to work her way through a preauthorization and takes patient satisfaction surveys seriously. Having worked on several quality improvement teams, she is familiar with total quality management principles and strategies.

"There are certain places that expect you to have all these 'primary care skills,' " Dr. Rapp said. "When I'm looking for jobs, I am able to say, 'Yes, I've been exposed to all these things.' "

More importantly, she said, her training instilled in her an appreciation for how rapidly the practice of medicine is changing, particularly in all its business aspects. "For us coming out now, we need to have an expectation that we will have to be flexible."

During Dr. Rapp's first year at Cedars-Sinai, both the institution and the department of internal medicine began to radically overhaul their operations. Situated in the heartland of managed care, the large independent academic medical center was beginning to ask itself how it was going to transform itself into an integrated system that could compete in a competitive managed care market. The center's internists, meanwhile, were beginning to recast their training programs to teach the skills required in the new system.

"Our programs in research and education should be relevant to our system," explained James R. Klinenberg, FACP, senior vice president for academic affairs.

Consequently, Cedars' 80 internal medicine residents now spend close to half of their three years in ambulatory care areas. Dr. Rapp, for example, is one of the 21 second- and third-year residents who spend four half-days a week working with a doctor-mentor in the large group practice now owned by Cedars-Sinai, the Medical Group of Beverly Hills.

"I've learned a lot more about preventive medicine because the patients are a little bit healthier. And you learn more about doing call-backs and about what it is like to be in practice," she said. "I'm sure starting a job will be an adjustment, but hopefully it will be a little less of an adjustment because I've seen how things work."

Other Cedars internal medicine residents work at several free clinics throughout Los Angeles and also staff the hospital's clinic, which has been reorganized to function more like small group practices, said Mark S. Noah, ACP Member, director of the residency training program. The program has also built into the schedule more elective blocks of time for ambulatory training. Residents are encouraged to use that time to study dermatology, outpatient gynecology, outpatient orthopedics and ENT. Everyone is required to do geriatrics and family planning and to learn to do and interpret stress tests, Dr. Noah said. All residents must participate in quality improvement teams.

Internal medicine residents in California today "need to know how to keep people out of hospitals, what is resource management, how to deal with not over-medicating, over-testing," Dr. Klinenberg said. "They need to know about outcomes, quality. They need to understand what length of stay is all about. We believe residents need to be prepared to deal with managed care."

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