A Letter to Senior Residents - Annals of Internal Medicine: Fresh Look Blog


Wednesday, April 25, 2018

A Letter to Senior Residents

Every July, scores of articles and opinion pieces, including a recent one in Annals, are written and distributed widely in an attempt to capture the many feelings being shared among an intrepid class of new interns (1). This yearly ritual pays homage to a crucial turning point in every physician's journey, providing helpful advice and a source of encouragement for newly minted physicians.

However, another similarly transformative process occurs within our ranks: every graduating resident or fellow in their final year realizes that some hard decisions need to be made in their own leap into a postgraduate medical education life.

Senior trainees—the rising third-year resident, chief resident, and advanced fellow—face the very significant prospect of deciding how they want to define their early career and where their first place of employment will be. The task can be terrifying. There are so many considerations, uncertainties, and decisions to weigh. Many of the feelings that have been described for interns (such as pride, fear, excitement, intimidation) apply.

Yet at the same time, it is a beautiful declaration of freedom. For the first time in many of our lives, we are given a proverbial paintbrush and a canvas of possibility. While most will choose employment based on location, pay, prestige, perception, schedule, family, comfort, and (hopefully) mission, a cohort of pioneers will take their plunge into “real” doctoring based predominantly on one important consideration: opportunity.

Opportunity not in the sense of career advancement and title, but rather in its purest essence: opportunity to build and realize a vision for a new dawn in health care. Significant transformation will only come from a generation of physicians who are empowered with the creative space to build a new system from the inside out. True thought-leaders should seek opportunities that actualize their vision for a health care system based on patient centricity, meaningful outcomes, and financial viability.

Take for example the “hospital-at-home” concept, first described and published in Annals over a decade ago (2). This novel program was used to treat stable hospital conditions, such as congestive heart failure, pneumonia, and cellulitis, in patients’ most comfortable and safe setting: their own residence. The program boasted lower complication rates, decreased costs, and higher satisfaction built on the sensible premise of engaging the right patients with the right amount of health care at the right time in the right place. Yet, how many early-career physicians are considering joining organizations where something like this is possible or even probable?

Similarly, consider true integration of behavioral health and primary care. ACP has strongly supported such integration since 2015 for clear reasons (3). Organizations like Cherokee Health have begun to demonstrate profound results (e.g., 68% reduction in ED visits and 37% decrease in hospitalization). The idea of co-locating behavioral health specialists in primary care for real-time consultation seems easy enough. But this integration is far from ubiquitous, limiting the ability of graduating trainees to join groups based on such best practices.

Fortunately, new opportunities are emerging for residency and fellowship graduates. Organizations like Iora Health and CareMore are pioneering fresh perspectives on health care delivery. Government entities, such as Medicare’s Center for Medicare Medicaid Innovation, are leading payment reform to encourage new methods for delivering care. Even in academia, where care innovations can be difficult to implement, we are starting to see progress. Mount Sinai Hospital, for example, has a fully implemented hospital-at-home program.

Amid the attention on those beginning their residency training, let us not forget those standing at the edge of another transition after a decades-long educational journey. My hope is that as a community, we will encourage and provide paths for a new cohort of pioneers who will pursue opportunity in organizations willing to use creative platforms to realize a future that our patients deserve.

  1. Taichman DB, Moyer DV, Laine C. A letter to new interns [Editorial]. Ann Intern Med. 2017;167:66-67. [PMID: 28672392] doi:10.7326/M17-1293
  2. Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798-808. [PMID: 16330791]
  3. Crowley RA, Kirschner N; Health and Public Policy Committee of the American College of Physicians. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med. 2015;163:298-9. [PMID: 26121401] doi:10.7326/M15-0510


  1. What you write is eminently correct and the future of healthcare delivery but you forgot one VERY important delivery method and that is telemedicine which will allow marked improvement in access and timeliness at a seriously lower cost with equal or better outcomes.

    1. Victor - I totally agree that telemedicine, virtual visits, and other tech-enabled enhancements will dramatically improve the accessibility and quality of clinical care. Here is a great position paper from the Annals of Internal Medicine that lays out much of the framework and definitions around telemedicine: http://annals.org/aim/fullarticle/2434625/policy-recommendations-guide-use-telemedicine-primary-care-settings-american-college.

      As we continue to push the boundaries on things like artificial intelligence, machine learning, and connecting with our patients in new and novel ways like telehealth, there will be such a fresh petri dish for innovation. This is exactly what I mean by encouraging newly minted clinicians to think outside the box and seek opportunities that will truly let them build this updated healthcare infrastructure. I look forward to seeing the many amazing advancements that come from a generation of physicians who start to question the status quo and push our conventional wisdom. Thanks for your comment.


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