Life Rich Pageant: Patient Diversity & Tulane’s Clinical Sites

Patient Volume and Diversity

The Importance of Patients
It is no secret among the educational elites that while we spend our careers developing curriculae and conference schedules, the most important element to medical education comes from the patients a resident sees. Having a diverse patient base is requisite for great medical training, and having a large volume of these patients consolidates the learning.

Diversity of Disease
There is no greater diversity of people, nor of disease, than that found at Tulane. The VA Medical Center, Tulane Hospital, and Charity Hospital may well be the source of the greatest diversity of disease possible. The Tulane resident receives exposure to diseases that most residents in the US will only read about. Yellow fever, malaria, first diagnosis of congenital heart disease in adults, sarcoid, lupus, tropical sprue, fungal lung disease, West Nile, leprosy, are only a few of the examples that are frequently seen on the Tulane service. Combine this with the “bread & butter” disease seen at the VA, and the high-end technical disease seen as part of Tulane’s quantenary referral service (abdmonial, liver, renal, hearty-lung transplant; bronchial stents, left ventricular assist devises, etc), and you have a patient experience that is matched by none.

Diversity of Severity of Disease
The mission of the Tulane Team is to re-invest a New Orleans patient population that has been previously disenfranchised, and we are working hard to fix the historical problem of lack of access to primary care. The unfortunate consequence of lack of access to primary care is that diseases frequently progress to the severe end of the spectrum. If there is a silver lining, it is that the Tulane resident has the opportunity to see disease at its most severe manifestations. On a spectrum from the disease’s initial onset to late-term consequences, the Tulane resident sees it all. This allows us to better appreciate the potential consequences of early disease, and to heighten our aggression in treating this disease. It also furthers our to ensure that each of our patients enjoys their right to have primary care.

 Diversity of People & Systems
But most importantly, the Tulane Resident sees a diversity of people independent of their disease.
Remember, requisite for becoming a great physician is a becoming a great person, and requisite for becoming a great person is understanding and appreciating diversity. There are few cities that have this type of diversity: New York City, San Francisco perhaps; New Orleans for sure. Since New Orleans is the “Ellis Island” to the Americas, your patients will be Cajuns, Creoles, African-Americans, Caribeans, Mexican-Americans, Central-Americans, and on and on. These people will make you a better person, exposing you to new beliefs, customs and traditions. It’s a rich life experience in the Big Easy… one that you will never regret.

THE GENERAL MEDICINE SERVICES
A central feature of Tulane’s training program is that all patients are admitted to a general internal medicine teaching service. There are no non-teaching services at Tulane, and there are no private attendings. The Tulane resident teams are the gateway for every internal medicine patient admitted to our three hospitals. This ensures that the Tulane residents have maximum autonomy: there are no private attendings abusing the residents by barking orders and not teaching. The teaching hospitalists, chosen for their teaching abilities, supervise all of the general medicine teaching services. They have been trained to ensure that it is the resident team, empowered by Resident Rounds (where the attending is not present), that makes all of the patient-care decisions.  The fact that all patients move through the general internal medicine teaching teams also keeps the residents’ exposure honest: absolutely anything could be encountered on a call day (acute MI, Crohn’s, sarcoid, HIV, acute lupus, stroke, undiagnosed malignancy, etc.), and this keeps the resident’s assessment honest. It also ensures that the Tulane resident leaves training with the valuable skill of being able to managed multi-organ disease simultaneously, trained to think of the consequences of her intervention to fix one organ on other organs.  It is not the same to be in a program where the patients are pre-triaged (i.e., the resident on a “renal” service more or less knows that all patients admitted to him will have some renal problem… and only patients with renal problems will he see). Further, while Tulane Hospital serves as quantinary care center (referrals from tertiary care centers in the Gulf South), almost all patients admitted to the Tulane Internal Medicine services are presenting with undiagnosed disease. This is important in your development at this stage of your career. It is not the same to work within a residency program that solely admits patients from primary providers who have already diagnosed the disease. 

This also allows residents who are on the subspecialty consultation services to maximize their exposure to multiple patients. Since they are not tasked with the day-to-day duties of managing these patients (i.e., discharge paperwork), they can see a greater volume of patients with the subspecialty disease (i.e., more cardiology, GI, ID, renal disease, etc.)

PROCEDURES AND STUDIES
The final component of the patient exposure at Tulane is this tenet: We do all of our own procedures, and we read all of our own studies. The presence of the teaching hospitalists throughout the day (i.e., they have no clinic or procedure to rush off to in the afternoon), ensures appropriate supervision for all procedures, and more importantly, ensures that procedures are not farmed out to other services (i.e., interventional radiology, pathology, surgery, etc.). At the conclusion of your intern year at Tulane, you will have fulfilled all of your procedural minimums for the whole of your training: central lines, lumbar punctures, joint tabs, pericentesis and thoracentesis…. And this will enable you to supervise these procedures over the next two years, further increasing your procedural competence. Indeed, Tulane will offer you the opportunity to perform procedures that have been long since lost in most training programs: bone marrow biopsies, intubations, PICC lines ,etc. Supplementing (and empowering safety) your procedural training is the six-million dollar Tulane Virtual Hospital (simulation center).

The Tulane resident also learns to read his own studies… formal training in reading echocardiograms, radiographs, EKG’s, urinalysis, peripheral blood smears, MRI’s and CT’s enables the Tulane resident to interpret the most common diagnostic tests, even when the “experts” are not available.

Charity Hospital:

Charity Hospital was founded in 1737: fifty years before your country (assuming that ratification of the Constitution in 1787 was the start of the USA). It is the longest continually running public hospital in the country. It will be there long after we have all come and gone. Tulane’s involvement with staffing the Charity wards dates back to 1834. Almost since it’s inception, Charity and Tulane have been partners in delivering healthcare to the underserved. Over 270 years, there have been six buildings that housed the Charity Institution. The most recent of which is pictured above.

Prior to Hurricane Katrina, plans were set in motion to replace the 75 year old building, and the new Charity Hospital will find its place next to the Tulane medical complex (between Tulane Avenue and Canal Street). For now, the Charity institution operates through University Hospital, that sits four blocks from the Tulane Medical School, Tulane Hospital and the VA. It has 350 beds, and the average daily admission census to the medical service is 11 per night. There are no subspecialty services and no patients managed by private physicians at Charity, so all admissions go to the general medical ward team (the residency team). There are four teams, and each team is comprised of one attending, one resident and two interns (plus medical students). The ICU is comprised of three teams of one resident and one intern per team (every third night call). So it is that Charity’s history continues to ebb and flow, but it always keeps marching on…as it will continue to do, and it will be Tulane Medicine that lead’s that march. That’s the nice thing about organizations and people who have a mission statement that is pure and right: there is nothing as powerful as an idea whose time has come.

Tulane Hospital:
Tulane Hospital is owned by HCA, and in a partnership with the Tulane Medical School and Tulane University, provides full service coverage ranging from indigent health care to referral-based care to the highest level of technologic services. It is the largest fully functioning hospital in Orleans Parrish. The average admissions per night is 14, and admissions cover all subspecialty areas. As with Charity, there are no subspecialty services and no patients managed by private physicians, so all admissions go to the general medical ward team (the residency team). There are four teams (every fourth night call), and each team is comprised of one attending, one resident and two interns (plus medical students). The ICU is comprised of four teams of one resident and one intern per team (every fourth night call).

Veterans Affairs Hospital:

The VA Hospital is in the process of building a new hospital facility that will be located within blocks of Tulane. For now, the VA service is fully-functional as leased space through Tulane Hospital. The VA service has separate residency teams (but still Tulane residents) from the Tulane teams (see above). Like all VA’s, it serves as the referral location for all VA admissions in the area, ranging from Western to Mississippi to Eastern Texas. It provides full service coverage ranging from general medicine to subspecialty care. The average admissions per night is 5, and admissions cover all subspecialty areas. As with Charity & Tulane, there are no subspecialty services and no patients managed by private physicians; all admissions go to the general medical ward team (the residency team). There are four teams (every fourth night call), and each team is comprised of one attending, one resident and one intern (plus medical students). The ICU care is provided by the Tulane ICU teams (see above).