Amanda Wilde (Host): A look at St. Clair's Internal Medicine Residency Program and Graduate Medical Education on this episode of Curating Care. A podcast brought to you by St. Clair Health. Expert care from people who care. I'm Amanda Wilde, and my guests are St. Clair Health Internal Medicine Residency Program Director, Dr. Kristen M. Livesey, along with Associate Internal Medicine Residency Program Director, Dr. Mallory Ciuksza. Thank you both for being here to talk about these educational programs.

Mallory S. Ciuksza, MD: Thank you.

Kristen M. Livesey, MD: Hi. Amanda. Thank you.

Host: So you're the leadership really of this transformation of St. Clair into a teaching hospital. But for context, let's explore first, just quickly, what brought each of you to St. Clair? Can you tell us a little bit about your journey, Dr. Livesey?

Kristen M. Livesey, MD: So I am originally from New Jersey. I have been in Pittsburgh now for, gosh, about two decades. I originally moved out to Pittsburgh to go to undergraduate at Carnegie Mellon University. I did all of my medical training in Pittsburgh. I was at the University of Pittsburgh Medical Center for my residency training.

I briefly left and worked at Mass General for two years, returned back to UPMC and worked there. And then I was recruited to work at St. Clair about five years ago, and this really has been my home. Advocating for patients has been really central to who I am as a physician and my identity, and I was really drawn to St. Clair because of their unwavering commitment to clinical excellence, but really their patient-centered care. They have a lot of accolades in terms of being a Leapfrog A grade and CMS five star hospital, but it's really their commitment to the people and about putting the patient first. That was what drew me into this institution and it's really a place where my voice has been heard and I've really felt empowered to be able to advocate for patients and make a lot of system level changes.

And it's been really inspiring to be at an institution like this, and it is why I am so excited for our new residency program to be starting here.

Host: Yeah, you're part of a growing new branch of what is happening at this hospital, and obviously, Pittsburgh's been some kind of magnet for you as well.

Kristen M. Livesey, MD: Yeah, it just keeps drawing me back. I love Pittsburgh.

Host: Same question, Dr. Ciuksza. What would you like to share with our listeners about how you ended up here today?

Mallory S. Ciuksza, MD: Sure. So I was born in the Pittsburgh area. My dad was actually born at St. Clair Hospital. But I grew up in a suburb and I also did my undergraduate at Westminster. And then I trained in Philadelphia at Drexel and then at AGH for my residency. And I came here directly from my residency after my chief year. That was about eight years ago. So I was looking for a practice with some experienced physicians who could teach me how to practice at the top of my license and how to be a doctor in the community and also a doctor who rounded in the hospital and saw those patients in both locations.

So that was really important to me. So I joined a practice with some senior doctors. Dr. Antonio Roselli is my longest standing partner and mentor. And he always loves when I tell people that he's been doing this since I've been in kindergarten. But I see that as such a huge part of my reason for staying here and reason for, you know, continuing to work in this community is because he really shaped and taught me how to do this work, with efficiency that allows me to live my life and joy and patient care and being at an agile institution like St. Clair, and I think this really echoes what Kristen said; you have the opportunity to make change for your patients here. And that's so important to me, being able to work in a place where my voice is heard and valued allows me to continue to feel kind of renewed in this hard work. Because it's really hard to take care of patients, right?

Primary care is difficult. So that's one of the things that really has kept me in this space, and I'm delighted to be able to grow and to take on this leadership challenge here at this institution. We're really excited about teaching residents to work in a primary care setting.

And I will say, Kristen has also been an incredible advocate of helping to shape this program around the idea of teaching residents to do work in the primary care setting for the community, because that's what this community needs. So all of those things have sort of kept me here and kept me loving the work that I do.

Host: Yeah. It sounds like you really are supported by the institution, and you mentioned Dr. Ciuksza, the agility of the institution and keeping that in mind, let's dive into why St. Clair is becoming a teaching hospital. What was behind that decision, Dr. Livesey?

Kristen M. Livesey, MD: So I think several different factors. The main factor returning to patients is, it is the number one thing that our community needs. So if you look at, we do a community health needs assessment. Access to care is the number one need identified by our community. This hospital was founded by members of the community and we're very much trying to respond to that need.

So on that same survey, 12% of patients said they couldn't get an appointment for a very long period of time, 20% of the community doesn't have a PCP, 30% of them said that their care was affected by access to general screenings that they just couldn't get to. And this is in the background of about 20 physicians who have left or retired from our region.

And Pennsylvania as a state, is ranked forth in terms of training physicians in primary care. But we are well below the national average in terms of physicians actually staying in the state that they train. That's largely because there are a lot of large academic medical centers that many of these residents are fantastic and wind up training in advanced fellowships and leaving the state to do that.

And we really want to create something unique that allows our residents to stay and hopefully build a pipeline of physicians who want to stay in our region and practice. It's important because this is in the background of a large national physician shortage, and PA is basically situated to feel that deficit more than other regions.

So nationally by 2036, there will be an 86,000 physician shortage, and the largest growing shortage is in primary care, which will be about 50,000 physicians. So we are very much trying to be part of the solution, to train our own pipeline of physicians to really carry on the legacy of this hospital that was built by and created by community members to give back and serve to the community who really desperately needs more primary care.

Host: You know, the way you've both spoken about the project makes me wonder, why it was a priority to lead this opportunity for each of you. What are you bringing to this that excites you and makes you excited to do this project? Dr. Ciuksza, can you start us off in that direction?

Mallory S. Ciuksza, MD: I was kind of barreling down the path of doing education at the end of my residency. I did a chief year, which is basically an academic teaching year. But I took a hard left into strictly community-based practice because I really wanted to get good at what I was doing. I saw some of my best teachers being people who had just a depth of experience, and that's part of why I sought out that mentorship. And after, five to seven years of doing this work full-time in the community, of building a large patient practice for myself and helping to build one for our greater practice overall and solving problems in the healthcare system; I really felt called in a way to teach how to do that in a very directed fashion. So a huge part of what we're doing with this residency is creating doctors who feel confident and comfortable stepping from their residency into a clinic primary care practice, or into a hospital primary care practice.

I think a lot of people who leave their training in large academic centers and in many places, feel a little bit scared of that. They feel scared of seeing the volume of patients that they need to see, they feel scared about joining a practice that where there may be not as connected to a hospital and then the other specialists who are there.

And it takes a very directed effort and I feel that our practice is situated to be able to help provide that, to help these young physicians understand how to do this work for the community, how to be accountable doctors who understand and feel the weight and the importance of their work while giving themselves the space to breathe and to be able to take breaks and rely on each other.

We have a really good team and so when I kind of stepped back and looked at what we had built; it was really clear that we were in a good place to teach young doctors how to do this work. And again, Kristen has been such an advocate for our practice and giving me the bandwidth to design that. So that's really inspiring to me.

Host: That just kind of leads me to another question, but I do want to give Dr. Livesey a chance to answer that question about why it was a priority to be part of leading this opportunity, why that role was important at this stage in your career.

Kristen M. Livesey, MD: I have always felt that teaching has been in my genes to some degree. My mom is a retired third grade teacher, so she's always been one of my role models and I think there's so much more to medicine than what we learn in textbooks. And when I reflect on my identity and who I am as a physician, it is because of the countless physicians who were generous of their time and taught me the art of medicine.

It is so meaningful to me to be part of a team who is able to give that to the next generation of physicians to teach how to truly listen to patients, how to take compassionate care of your patients. How to really think through what patients want, what patients need, what are their goals, what's important to them as we are working together on a treatment plan with our patients, and really taking that medical knowledge to the next level.

Really how we have built this program is thinking through who are the kinds of doctors that I want taking care of my family member? And that's really the lens through which we created a lot of the curriculum and that's the north star in terms of how we teach the next generation. Because patients need physicians who are different, who are truly listening to them, to what their needs are and meeting them where they are. And we need to do that for our patients and for our community.

Host: Dr. Livesey, as you have developed this program, what can you say in terms of what patients can expect in terms of medical care?

Kristen M. Livesey, MD: So there are going to be a lot of changes as this residency starts at the hospital. There will be two different residency programs. So our residency program is the internal medicine residency, and there will be eight residents starting in our program that will be at the hospital for the next three years as they continue through their training.

And then we have 12 transitional year residents who will spend a year with us doing fundamental clinical skills before they go on to advanced training in things like radiology, dermatology, anesthesiology. And really the patients who are admitted to the hospital and in many of the outpatient settings will hopefully have the privilege to get to participate in the education of our residents.

I learned a ton from the experiences of patients because you are able to really understand what the patient is experiencing. What does it mean in terms of the impact on their lives and what they feel on a day-to-day basis from patients. I look back at my residency and when I'm treating patients with different diseases now, I go back to particular patients that I saw who explained their experience to me and draw back on those experiences.

So they will really be partners in terms of teaching our residents. So the patients will get to see our resident physicians who will be supervised by the attendings that they already know, and you'll basically get two brains for the price of one. So you'll have residents getting to spend extra time with you, really getting to apply some more current, up to date medical knowledge, bringing everything up to speed, and it really should be a positive experience for patients.

Host: And then Dr. Ciuksza, can you break down what the resident clinic, what residents can expect?

Mallory S. Ciuksza, MD: What residents can expect and what patients can expect. Absolutely. So in the resident clinic, as a patient, when you come to the office, you're going to be paired with a resident and a precepting doctor. So that will be the attending doctor who's closely supervising all the care that you receive from that resident.

But your resident is seated in the position of your PCP. So they would be the ones coming in, introducing themselves, asking you questions, taking a thorough history, doing a physical exam, interpreting your labs, interpreting your studies, and then coming up with a care plan together with you, and ideally moving you through the continuum of your health.

And so making a plan for your next visit, and then making a plan for follow up and any specialist referrals, et cetera. All of this will be carefully supervised in time of the visit, and also between visits. So let's say you needed some lab work done. That would be first reviewed by the resident and then also by the preceptor to make sure that the patient care is absolutely safe, but also to make sure that the residents have the opportunity to be in the driver's seat, right?

You can't really learn to drive from the passenger seat. So we've designed this to maximize their autonomy at each stage of their learning and then to progress them through their development of their autonomy, while keeping the patient experience at the center. So in our office, for instance, you'll have the opportunity as a patient in a resident clinic to take more time with your doctor. And you'll typically see the resident and the preceptor, me for part of the time, or one of our other doctors who's participating as a preceptor. So it really is two heads for the price of one. And also, at this point, I'm almost 15 years out from my medical education training and I'm really excited to learn from these doctors and to use this as an opportunity to continuously learn from my colleagues. Right? That's a huge part of being a doctor in a practice is that we all teach each other, we all work together, we run cases by each other. We will model that for the residents, but I'm also excited to learn from them and to have that academic rigor injected into our care.

Host: Dr. Livesey, you mentioned that the program was born out of providing access to care, and Dr. Ciuksza just sort of talked about the constant growth that doctors are having throughout the program. How does the program grow over time? How do you see the future of the program?

Kristen M. Livesey, MD: So each year there will be for the internal medicine residents, we will get eight new residents per year for a total of 24 residents. When we are at the full, what we call complement of the program. And then each year for the transitional year residency, we get 12 new residents each year. And then we have some exciting new hot off the press news that Dr. Budway, who's our general surgery program director, has also applied to start a general surgery residency program. And we're hopeful. They're undergoing their accreditation, but we're hopeful that that program may start next July. So we are really excited about the growth and expansion of our graduate medical education programs over time.

And we are carefully looking in selecting the various different programs, about what are the community needs and that's how we're selecting which programs we are starting and when in terms of primary care was the largest need, which is why we started with those programs. General surgery is another national need that has been identified, and also a regional need.

So we are sort of working through what the community is asking for.

Host: Well, Dr. Livesey, Dr. Ciuksza, thank you so much for this information about these educational programs that are really a key to the future of healthcare. We really appreciate your time and insight and all the work you do for the future of healthcare at St. Clair Health.

Mallory S. Ciuksza, MD: Thank you. Thank you for the opportunity. Yeah.

Kristen M. Livesey, MD: Thank you for having us.

Host: To learn more about graduate medical education at St. Clair Health, visit stclair.org/graduatemedicaleducation. To schedule an appointment with Dr. Ciuksza, please call 412-942-8500. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Curating Care, a podcast brought to you by St. Clair Health.