OUR GENERATION

Residency versus the real world of ob/gyn

By Elizabeth Lapeyre, MD

No one prepares you for the day-to-day stresses—like keeping Internet-savvy and demanding patients satisfied—that take multitasking to a whole new level. Let's mentor residents and newcomers so they don't repeat our mistakes. It could help preserve our specialty.

Everything I need to know I did not learn in residency. I've been in practice for a year, and I experience this more and more each day. My residency program was accredited by the Residency Review Committee, and I trained under excellent and experienced faculty. But even the best training program does not prepare you for the challenges of practice. The reality is that medicine has become a business, but our training has changed very little to accommodate its current practice.

Most physicians are intelligent and have a tremendous work ethic. Many of us probably could have excelled as lawyers or in the corporate world. But we chose medicine, and moreover, obstetrics and gynecology. Why? The standard answer is that we like to operate and we enjoy having long-term relationships with our patients—the two components that set ob/gyn apart. The current buzz in our specialty is all about doctors having more business and more legal knowledge, and there are CME courses on these very topics.

As a specialty, we should work together to educate those who follow us so they don't make the same mistakes we did. Mentoring residents and those who are new in practice could help preserve our specialty. The differences between being a fourth-year resident on June 30th and a staff physician in practice on July 1st are staggering. The major issues include accepting a higher level of responsibility; managing office patients, surgeries, and deliveries (often at the same time); and encountering more demanding patients.

Fourth-year residency is a time in your career when your confidence is soaring. You are the "bulletproof" doctor. Your skills are improving, and surgery is handed to you. Best of all, you are ultimately responsible for nothing. Therein lies one of the most stressful transitions after residency. In residency, "crashes" were exciting. As a staff physician doing my first emergency cesarean delivery, I was not having nearly as much fun at 2 am as the resident across the table from me. The dual burdens of responsibility and liability in practice are very different from training. What I did not expect and what no one told me about were the stresses of day-to-day practice.

All ob/gyn residents must have the ability to multitask, but the word takes on an entirely different meaning in clinical practice. You must

• Round on hospital patients

• See clinic patients

• Manage laboring women

• Operate

• Follow up on labs and tests

• Answer phone calls

• Schedule surgery

• Interact with office staff, nurses, and other doctors and (for some of us)

• Teach residents.

Added to this, you

• Try to stay on schedule

• Make each patient feel like you are spending more than the 5 to 10 minutes that is truly allotted to her.

How did practice become so stressful? Medicine is now about numbers, production, and customer satisfaction. Hospitals view patients as health-care consumers and are now sending them surveys assessing everything from the friendliness of the front desk to how long the wait was in the waiting area or exam room. A delay in your office because of surgery, a delivery, or a problem in your personal life can translate into a disgruntled patient. One way to manage this is to have your staff tell your patients why there is a delay and offer to reschedule their appointments. Some patients will wait, while others may reschedule or choose to leave your practice. Being honest with your patients and respectful of their time will result in better patient satisfaction. This sounds like common sense, but it's something no one ever told me. In residency, many of us train in places where patients are expected to wait for hours and hours. Clinicians in practice cannot survive with that kind of philosophy.

Residency also does not prepare you for the kinds of patients you may see in practice. Most of my patients still trust physicians and follow recommendations made to them. However, the number of Internet-savvy patients is growing, and they can crush your schedule if you allow it. We have all had one of these patients or know a colleague who has. She's the woman who has "done a tremendous amount of research" and knows her diagnosis and treatment because she read all about it on the Internet. She then proceeds to tell you what prescription or herbal remedy she needs. I have even had patients ask me to read a book on an alternative therapy and call them to discuss it. My husband, who is an attorney, could bill for this "pleasure reading" and the phone call. But I cannot, and some would argue that as a clinician, I should not. The point is that patients are becoming more demanding of our time when most of us have less time to give.

For many of you reading this, none of what I've said is news. However, it is news to the people now finishing training and starting practice. Knowledge is power, and passing our hard-learned lessons on to those just starting out could help them tremendously. It's worth repeating: Mentoring residents and those who are new in practice could help preserve our specialty. It certainly would help new physicians transition into practice more smoothly. Too often new ob/gyns in practice do not ask for help or do not know whom to ask for help. If you are thinking, "been there, done that" as you read this, consider being a mentor. It might rejuvenate you and can only serve to improve our specialty.

"Our Generation" offers real-world solutions to problems faced by ob/gyns new to practice. Written by young readers for young readers, each column sketches out a specific problem and offers practical "street-smart" advice. Columnists Steven J. Fleischman, MD (sfleischman@snet.net), Elizabeth Lapeyre, MD (Lizlapeyre@yahoo.com), Maria Manriquez Gilpin, MD (mmgilpin@yahoo.com), and Editorial Board Advisor Nanette Santoro, MD (glicktoro@aol.com), welcome your questions, comments, and ideas. Let them know how life is going in the trenches.

Submission of a letter or e-mail constitutes permission for Contemporary OB/GYN, its licensees, and its assignees to use it in the journal's various print and electronic publications and in collections, revisions, and any other form of media.

DR. LAPEYRE is a staff ob/gyn with the Ochsner Clinic Foundation Memorial Campus in New Orleans, Junior Fellow Chair of American College of Obstetricians and Gynecologists District VII, and a former Junior Fellow representative to the Council on Resident Education in Obstetrics and Gynecology.

Surviving the real world

New physicians need to be "mentored" by host practices that understand consumer issues—as well as productivity.

By Barbara Weiss

Dr. Lapeyre describes a universal dilemma for anyone starting a new job: the burden of new responsibilities and the fear of not measuring up to expectations. As consultant Judy Bee of Practice Performance Group in LaJolla, Calif., points out, "Engineers responsible for astronaut safety feel pressure unlike any they experienced in grad school. Executives who can be fired as a consequence of an error are more stressed than they were in their MBA programs."

What's unique about physicians, of course, is that they start out in their first real job in medicine having already reached the top of a long educational and training ladder. By the time they graduate from a residency program, obstetrician/gynecologists are justifiably proud and perhaps a little vain about their expertise and knowledge—which, after all, is bound to be more up-to-date than those of their new colleagues. It comes as a shock, then, to find that the culture of their new employment places altogether new responsibilities on their shoulders.

Dr. Lapeyre says, correctly, "Even the best training program does not prepare you for the challenges of practice." But should it? Learning the etiquette of customer service, respect for informed patients, and how to cope with the administrative hurdles to payment are part of the post-training education. "As a potential consumer of sophisticated medical services, I don't want any of physicians' precious training hours devoted to such matters," says Bee. "These things are relatively easy to learn later."

The key, as Dr. Lapeyre herself has discovered, is for the specialty to "work together to educate those who follow us." This is not simply a matter, however, of senior doctors taking juniors under their wings. The issues the author defines are too important and too global for one ob/gyn, especially a newly minted one, to tackle alone or even with a mentor. Respect for consumers' time and intelligence should be a universal aspect of the practice. The entire office, from the senior attendings to the back-office staff, should be treating patients with patience and respect as a matter of course. Yes, everyone is hassled and stressed these days, but a simple apology if a patient has a long wait or a courteous answer to a question takes no more time than rudeness—and may save you time in the long run.

All of the timesaving strategies that consultants suggest need to be implemented throughout a practice if the practice is to be successful. For example, Chris Zaenger of Z Management Group in Barrington, Ill., suggests using the assisting staff to ease the time burden of the doctors. Nurses can triage calls, perform nonstress tests, and educate patients whenever possible. In postpartum visits, physician time can be minimized unless there are abnormal concerns; nurses can address issues such as diaper rash, crying, feeding, and other routine education. In addition, educational handouts on diverse health-care matters can be prepared or easily obtained to help answer many patient questions.

Even for Internet-savvy patients, it's the practice as a whole that needs to put in place a strategy. In fact, the youngest, newest partner (possibly the most computer-literate) might volunteer to take the lead in this. Some practices offer patients the option of sending physicians questions by e-mail—a time-saving device that allows ob/gyns to answer at their leisure. Others have developed handouts that suggest reputable online sites where patients can look for reliable health-care information.

Patient visits may be especially time-consuming in obstetric practices where physicians rotate call and all obstetric patients see every doctor in the group at least once. In these circumstances, brand new doctors will inevitably see many prenatal patients they don't follow as regularly. Zaenger suggests that these visits be used as introductory "getting-to-know-you" sessions unless there's a pressing medical concern. Another timesaver that consultants recommend is for physicians to use every "no show" gap to return calls, review charts, read test results, etc.

Finally, issues of time pressure are always important when considering doctor productivity—especially when productivity determines physician income. Judy Bee recommends that new physicians be hired on a flat salary basis. "Any new physician in a practice, whether newly out of training or just new to the area, must establish relationships with patients. The first year is when you need to take the time to get to know the core of your practice. As the patients return, visits will be shorter. Expecting a new physician to produce at the same level as the established physicians will just drive everyone crazy."

Because full reimbursement for obstetrics is delayed until delivery, Bee recommends that straight employment extend for the first 2 years. The productivity formula for the practice can be applied to a new hire from the start, but income should not be based upon the figures until the end of the second year. Meanwhile, the new physician should of course have the full support of a consumer-friendly practice that treats its patients and staff respectfully.

MS. WEISS is the former Editor of Medical Economics, OB/GYN Edition.

 

Liz Lapeyre. Residency versus the real world of ob/gyn. Contemporary Ob/Gyn Sep. 1, 2004;49:33-35.