AAMC Reporter: June 2005

A Day in the Life: Residents on Rounds

By Whitney L.J. Howell

Kimberly Zuzak, a resident at Duke University Medical Center

Morning rounds on the cardiac transplant floor at Duke University Hospital were going smoothly for Kimberly Zuzak, M.D., a third-year family medicine resident completing her cardiac rotation. Then an urgent call came over the intercom system: "Assistance needed in the hallway at 02."

Immediately, Zuzak ran down the hallway with her attending physician, Joseph Rogers, M.D., Duke's medical director of cardiac transplant, and Cary Ward, M.D., a cardiac fellow also on call. A post-transplant patient they had just visited had collapsed in the hallway.

Doctors gathered around the patient, beginning chest compressions and calling out for medications as they wheeled the patient back to his room. They worked frantically for 15 minutes, but despite their efforts and three defibrillator shocks, the patient died.

For Zuzak, the crisis, while not a new experience, proved emotionally draining. She is new to the transplant rotation, having spent five years as a molecular microbiologist and immunologist before studying family medicine.

"As a medical student, I worked at the VA, so I've been to a lot of [heart procedures], but it was different because the patients weren't mine," Zuzak said. "It's stressful no matter who the patient is, but it was so sad because we were just in his room, and he wasn't symptomatic."

As frenetic as a cardiac arrest may be for someone who does not plan to specialize in cardiology, Zuzak's experience fits into the educational routine for America's medical residents. Every day, physicians in training encounter patients with which they are unfamiliar. Their knowledge is tested; their energy is drained, but at every turn, they learn something new.

Morning Conference

Duke University Hospital, where Kimberly Zuzak is completing her residency

A resident's day typically begins at 7:30 a.m. with the morning report. It is a time to discuss current patient cases with faculty advisors and ask them questions about a particular condition or treatment. Faculty advisors also offer advice on how to approach the medical exams. For residents at Duke University Hospital, the sessions usually last between 45 minutes and an hour.

On this day, Zuzak and four other colleagues learned how to categorize patients into low, medium and high cardiac risk groups when they first arrive in the hospital. Michael Blazing, M.D., assistant professor of medicine and medical director at Duke, gave them guidance on how to phrase questions so patients provide the most accurate information.

Residents quickly leave the conference table for the most physically strenuous part of the day, which begins at 8:30 a.m. Zuzak was at the hospital for a few hours already before starting her daily rounds. For the rest of the morning, she will be on her feet, checking on patients and updating their medical files.

Zuzak's rounds began with a frustrating scenario involving a 70-year-old patient who recently received a new heart. Although the patient's body was not rejecting the organ, his arteries and blood vessels started to constrict. Rogers, the attending physician, said nothing could stop the problem, including another transplant.

For the rest of the morning Zuzak practiced reading EKGs to identify any abnormalities and recognize patients with pacemakers. Rogers quizzed her about specific cardiology facts. In addition, Zuzak checked on a patient who likely will not receive a heart transplant because he contracted hepatitis C decades ago. Instead, he has a mechanical heart because implanting a foreign organ could weaken his immune system and cause the virus to flare up.

Heavy Load

Being on the cardiac transplant rotation is difficult as a family medicine resident, Zuzak said, because there is so much specialized information to absorb. She enjoys the challenge of learning about all facets of medicine but struggles with the combination of additional study requirements and clinical work.

"In a rotation that's outside what you'll end up doing, you just have to pick up what you know you'll need," she said. "The downside comes when you have to read a lot, and you know you don't have a lot of time."

After checking on patients, Zuzak finally has a few moments to rest her feet but not her mind. Every day, she attends a noon conference with presentations and discussions. Often doctors present their latest research results or discuss intriguing patient cases that offer some educational value for residents.

The rest of Zuzak's afternoon was split between admitting patients and working in the clinic. Many of the patients coming to the hospital had planned admissions, so she recorded a full medical history and wrote out treatment orders. She also admitted a few patients who came in unannounced, complaining of chest pain or problems with pacemakers.

Zuzak's clinic experience is different from other residents because she worked previously with inpatients at Durham Regional Hospital. Since several months have passed, many of her Durham Regional inpatients are now outpatients at Duke, giving her the opportunity to follow their progress.

"I've enjoyed being able to take care of these patients over time," Zuzak said. "Sometimes it's hard for them because they'll get a different resident every time they come in. This way they get a greater continuity of care."

Often clinic hours last longer than expected, and Zuzak's day will not end until well after 7 p.m., when her body is running on adrenaline. According to Zuzak, the most important thing for today's residents to remember is to always make personal time –no matter how small– a priority during the day.

"You always have to make an effort to eat and do other necessary personal things," she said. "Sometimes you're so busy that you don't really feel you have time to do those things, but you have to make the time."

Training Ground

George Washington University Hospital residents Rebecca Chatterjee, Jahan Tavakoli, Andrew Rickles, Sumeet Chabra, and James Walsh

Unlike Zuzak, not all residents find themselves in rotations outside their areas of expertise. But the resident's daily agenda is similar at the George Washington University Hospital.

Rebecca Chatterjee, M.D., a third-year internal medicine resident, is part of a larger group of 10 residents and two chief residents meeting for the morning report. During a recent meeting, they discussed at least two evidence-based medical cases with residency director Jehan El-Bayoumi, M.D., and Alan Wasserman, M.D., chair of internal medicine. One case involved a 39-year-old HIV-positive patient who had pneumonia complications. During her hospital stay, the patient developed many problems, and the residents exchanged ideas on how her care could have been improved.

After analyzing patient cases and answering several questions based on the medical board examination format, Chatterjee and her colleagues break into groups to check on patients.

It is only 8:30 a.m., but even with the early start, the days seem too short to provide the type of medical care the residents would like to offer. Their responsibilities often expand to include activities they have not trained for, Chatterjee said.

The first patient of the day was a prime example. A suicidal drug user asked a nurse how thick the windowpane was because he was planning to jump out. In addition to checking his medications and asking how he felt, Chatterjee and her colleagues reported his mental state and suicidal tendencies to the psychiatric unit.

Securing a psychiatric consultation for the patient took nearly an hour and several phone calls, and it was a test outside Chatterjee's internal medicine training. But it was also an opportunity for the chief resident, Dipsu Patel, M.D., to teach Chatterjee and her colleagues how the hospital handles similar situations. Before visiting the next patient, Patel quizzed Chatterjee's group about the advantages and disadvantages of involving the psychiatric unit in a patient's medical care. Patel also emphasized that doctors should only use physical restraints sparingly on patients needing psychiatric treatment because the bonds inhibit their personal rights.

Throughout morning rounds, Chatterjee's group treated many people on two floors of the hospital.

Sometimes being responsible for multiple patients makes it challenging for residents to share all pertinent details about individuals who for any number of reasons might be more difficult to treat, Chatterjee said.

"Having so many people involved limits communication," she said. "Sometimes we aren't able to do as good a job as we could."

A much-needed break came at noon, and the residents switched gears from the clinical environment to an educational setting. For Chatterjee and her colleagues, the lunchtime conference covered presentations on feeding tubes and sexually transmitted diseases. At the end of the reports, residents had the opportunity to question presenters about the research findings.

Clinic Consults

For the rest of the day, the group honed their techniques and bedside manner in the clinic where they consulted a wide range of outpatients either for check-ups or for specific ailments. Residents have clinic shifts four to five days a week. In any given week, they generally treat between eight and nine patients per day.

Consulting with patients in an outpatient setting allows Chatterjee an opportunity to work with a diverse group of patients, much like the ones she will encounter in her own practice. In addition, meeting individuals with numerous complaints helps to strengthen her patience and sensitivity as a physician.

Chatterjee and her colleagues did not, however, encounter any patients with overly complicated health problems. Most individuals had diabetes and were in for regular check-ups while others suffered from chronic ailments that needed periodic monitoring. The most troubling case involved a walk-in patient who demanded that doctors fill five prescriptions immediately. Concern over the medications prompted residents to send the patient to urgent care for a blood-pressure screening.

Although Chatterjee became a doctor to care for patients in need, her motivation for going to the hospital every day has other sources. She enjoys the camaraderie residents build through their shared experiences.

"Helping your colleagues is sometimes the best thing to look forward to," she said. "We're all hardworking and ambitious, and we're teaching each other things all the time."

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