Residency doesn't prepare you for these 7 important topics

There’s no doubt physicians entering practice today leave their residency programs with a tremendous amount of medical education and training; what seems like a lifetime’s worth of knowledge crammed into just a few, intense years of instruction.

Unfortunately, all the time residents spend on rotations, lecture, journal club, and myriad other obligations leaves little opportunity for getting oriented to the more mundane, yet absolutely critical components of practice. As a result, newly minted physicians are often completely unaware of the potential pitfalls they face as an attending, from liability insurance and malpractice to understanding their own employment contracts.

As the clinical leader of a 2,000-physician emergency medicine group, I see this issue all the time, both in the young doctors recruited to the group, and in the residents who train in the community program where I’m based.

To address it, I’ve started lecturing to those local emergency medicine residents on issues and problems to anticipate after their training is complete. We cover a wide range of topics — often chosen by the residents — which I have either learned about through hard-won, first-hand experience or from listening to my peers. Among the topics are:

Advanced practice clinician supervision. Nurse practitioners and physician assistants are caring for a growing percentage of emergency medicine patients. Most residencies offer no specific training in understanding these practices, their limitations and capabilities, and the implications of physician supervision. This understanding is vital for providing a safe work environment for APCs, supervising physicians and patients.

Contracting. Most graduating residents understand the importance of their employment contract. Many will perform good due diligence in presenting prospective contracts to an attorney or an attending for review prior to signing. Virtually all of them feel the contract offers them significant protection in their future employment. However, do they understand the contract their potential employer has with the hospital or facility where they want to work? Most of these contracts allow an unhappy CEO to demand termination of an individual provider for no cause. In these cases, the individual employee contract provides little protection. Surprise!

Credentialing. The typical emergency physician has little idea what goes into credentialing with a hospital or health organization because their employer insulates them from the process. By and large, most physicians find this a great thing. However, most also never realize the risk involved in credentialing forms that are filled out inaccurately.

Documentation. In addition to its importance in cases of alleged negligence or malpractice, documentation is critical for reimbursement. After residency, many physicians find their compensation tied to some measure of productivity, which often relies heavily on the quality of their documentation. This can lead to significantly less pay than anticipated as young providers struggle to make sense of a complicated electronic medical record.

Liability insurance. Residents typically have their insurance selected and provided for them without their input or understanding. After residency, they must understand the concept of covered activities, limits of coverage, terms, and options.

Malpractice and case evolution. There is a great deal of misunderstanding about this process. Most residents I talk to cannot define what constitutes malpractice, and even fewer understand the litigation process. Emergency medicine is a specialty with a great deal of risk, both in frequency and severity. A thorough understanding of this process is critical.

Performance metrics. Increasingly we practice in a world with measurements. Length of stay, door-to-doctor times and more are being measured down to the individual provider level. Resident physicians usually do not carry the burden of these measurements during training, and academic training centers often are not held to community standards. Perhaps most importantly, patient satisfaction looms large in the minds of every CEO because of the clear financial implications associated with this metric. Many physicians making the transition from residency are stunned to see their individual patient satisfaction scores posted in the department for all to see, along with patient comments.

A clear understanding of each of these topics is critical for a healthy and happy practice in emergency medicine. Resident physicians also tell me they want to learn about topics such as burnout, understanding employee benefits, “democratic” practice versus alternatives, and risky cases and their management. And not only do residents seem to appreciate the lectures, but more seasoned clinicians also show up to add value by sharing their personal stories.

I encourage all physicians still in training to seek out opportunities to better understand and prepare for what it’s like to practice after residency. And I welcome all my colleagues out there who, like me, learned some of these lessons the hard way, to share your stories, knowledge and guidance with the next generation.