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Posted by Ishani Ganguli November 18, 2011 07:00 AM
As I near the six month mark of my internship year, it occurs to me that my experience has mirrored, in some ways, the evolution of American health care.
I began the year working on the Ellison, a general medicine service with a traditional model of care. Among four interns, we split a list of 30-something patients and I was responsible for a cohort of up to ten of them. When I went home at the end of the day, I “signed out” my patients to the resident covering the floor that night. When I came back the next morning, that resident signed those patients right back out to me. I was intimately aware of every lab test and specialist consultation that had been ordered for the patient (at least, during the day) because I’d been the one to order them. As medical students, we’d been assigned individual patients and encouraged to take ownership of them, so this model felt familiar.
My next inpatient rotation was markedly different: The Bigelow is a team-based general medicine service that is unique to MGH. I became one of four interns sharing responsibility for up to 24 patients. We took turns playing different roles in their care - one day I was in charge of coming up with treatment plans for each of them, another day I scribed these plans onto daily progress notes, and a third day I admitted new patients to the floor.
This was quite an adjustment. I didn’t know my patients the way I had before. I had to rely on my colleagues to get things done and to adapt when their work styles were different than mine. On the days that I “ran the plans,” my medical decisions were easily scrutinized. Communication became even more critical - we had to update each other continually on what we’d done for each patient and make real time decisions about how best to split up our work.
As I got used to the Bigelow model, I started to enjoy myself. I got to work closely with my co-intern friends. With a list of 24 patients, and a daily exchange of ideas about their care, there was a lot more for me to learn.
Over the course of my six weeks (so far) on the Bigelow, it was increasingly clear that the model embodies the direction in which our health care system is headed. As we care for more complex and chronic illnesses in the United States, we have to coordinate this care across disciplines and health professions. Health care is more chaotic than in the days when one doctor truly did everything for a patient (even on the Ellison, I was far from alone). Seamless teamwork is a tough but critical part of fighting this entropy.
The challenges in the Bigelow model have become opportunities to adjust to this trend, both for us as residents and for the institution. For example, patients on the Bigelow reported (not surprisingly) that they were confused about the roles played by the multitudes of white-coats that entered their rooms each day. In response, each Bigelow team began to distribute face-sheets to patients with each team member’s name, photo, and role, and the reviews improved.
In our program’s efforts to comply with the ACGME’s work hour restrictions, the Bigelow model with its complicated schedule has taken a bigger hit than others. In the process, I’ve found that current residents, alumni, and program leadership are fiercely protective of the Bigelow as a unique training environment that breeds camaraderie and allows us to learn from our peers.
Though a service like the Bigelow is a nice testing ground for team-based care, it isn’t the whole solution - for one thing, we still don’t do a good job in medical education of teaching doctors the formal skills involved in teamwork and leadership. But I get why the Bigelow is such an important part of our program. If we can figure out how to work in this setting, we just might be better prepared to practice the team-based care that will be critical to modern medicine.
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