Transcription:
GME Program Featuring Internal Medicine

Melanie Cole, MS (Host): Welcome. Today, we’re talking about the exciting GME program happenings at Temecula Valley Hospital, and this time we’re featuring internal medicine. My guest is Dr. Joel Trambley. He’s the program director for the internal medicine residency program at Temecula Valley Hospital. Dr. Trambley, please tell us to begin with the mission of the internal medicine residency program.

Joel Trambley MD (Guest): Our mission is to train residents who will give excellent care to the patient’s in this area and will be on the cutting edge of internal medicine making sure that patients receive the best care for Temecula Valley Hospital and the other hospitals involved in our consortium. One of our goals is to make sure that these residents come here and give them a reason to stay in the area so that we can continue a physician presence here and address areas of unmet need and physician shortage.

Host: Doctor please give us an overview of the internal medicine training. What's involved for the residents? What does a typical day look like?

Dr. Trambley:   It varies quite a bit for internal medicine. The residents will do a lot of their time in the hospital on some service. They will do intensive care unit services, they will do general medicine wards or what are called hospitalist services at most of the hospitals, and they will be doing cardiology rotations at the hospital. Then we have a number of electives that vary between being fully outpatient and in a clinic or that may have overlaps between an inpatient experience—either to see inpatients or perform procedures—and an outpatient clinic. So, for instance, the hospital medicine service, the residents work from about seven in the morning until seven in the evening seeing patients in the hospital. But on their gastroenterology rotation they sometimes see patients in a clinic, but then come to the hospital in the afternoon to see patients who are sick enough with gastroenterology problems to be in the hospitals, and sometimes to do procedures with their teacher attending on those patients.

Host: So as you’ve mentioned cardiology and hospitalist, give us a little bit of information on the curriculum itself. What are some of the mainstays of study and areas of concentration for internal medicine?

Dr. Trambley:   Internal medicine often goes by healthcare for adults. So we don’t see children and we don’t do things like deliver babies, but what we do are all the parts of the body in some way that are part of internal medicine. So we do cardiology. We do nephrology about the kidney. We do pulmonology about the lungs. We do rheumatology. Those are just a few of them. There are many, many subspecialties of internal medicine, and we try to offer our residents experience in all of them at different points in their training.

We often deal with patients who have diabetes in the area that may have gone out of control. For those patients, also sometimes the specialty that helps with diabetes is endocrinology. So they experience somewhat specifically in that as well. Those patients when they come to the hospital are usually cared for by our hospitalists directly. They also deal with infectious disease patients, folks who come in with pneumonias or other unusual infections sometimes. Our residents take care of those patients. They really just try to learn everything they need to know to take care of the medical needs of a patient in the inpatient side where they are around in hospitalists, as well as on the clinic side where they might be someone primary care physician.

Host: Well, I'm so glad you mentioned that Dr. Trambley because that segues beautifully into my next question. As internal medicine physicians also tend to be primary care physician, what are you looking for in their personalities? What are some qualities in your residents that you really like to stress and strive to achieve?

Dr. Trambley: We want a lot of things from our residence. We really ask for a lot in our process for looking at who would be a resident here. It involves interviews, it involves looking at a lot of data that goes through a joint application process that residents can use in many programs. We look for diversity in our population of residents. We try to see a group that reflects the community that we serve. That’s a goal of most programs. We look for excellence and academics, and we want to make sure that these residents are ready to be knowledgeable and able to learn everything we need to for excellent patient care.

But we also look for humanistic qualities that suggest that these residents will be people who can be compassionate and caring physicians and will always have the best interest of their patients at heart and understand how to work with a patient together as a team to make that patient’s healthcare better. A team approach in medicine is becoming increasingly important. Not just with the idea that there are so many other professionals—nurses and case managers and physical therapists—who really play a major role in the patient’s healthcare, but also that the patient themselves has a lot to say about their healthcare. Not only in terms of information that might not be obvious in other parts of what a physician gets are a history from a patient, but also in a sense of what they want from their healthcare and how to weigh the goals of what they want to do versus side effects and risks of procedures and medications and other interventions that we do.

Host: What a good point that you make Dr. Trambley. So using all of those qualities and that excellent education, how does it help improve patient and population health outcomes? In a cost effective manner, how does the way that they're working as internal medicine providers help those outcomes?

Dr. Trambley:   Usually the way that we improve healthcare cost effectively is by doing things that are proven to work and avoiding things—sometimes things that we’ve done for years—that are proven not to work. So data has a large role to play in this as does standardization of care and protocolized care. So one of the things that’s important is for very sick patients with either maybe a stroke or a bad infection that has led to what we call sepsis where it’s sort of effecting their whole body—things like their heartrate and their blood pressure—there are interventions that we know work for these patients. If they get them, they will, on average, do better. So we try to institute care packages or power plans or order sets that make it easy to include these things, and then make sure that our trainees know what should be included to provide excellent care. These are some of the things that groups that rank hospitals look at to see are you doing everything that needs to be done for a stroke or perhaps for heart failure.

Heart failure’s a huge one that’s been studied a long time. There are medicines like aspirin sometimes and beta blockers and ACE inhibitors and cholesterol medicines that we know are good for people with heart problems. We want to teach all of our trainees when those things are appropriate and make sure that they are happening. We use computers and computer physician order entry to do what we call decision support. To have something backing up to say, “Hey, when you discharge this patient, did you do all the things that we know work to keep these patients healthy and keep them out of the hospital for longer.

There are similar things on the outpatient side where you make sure that those medicines continue, or you add things that we know help in certain circumstances. Really making the best use of what we know works and avoiding what we know doesn’t work, I think, is one of the major points of providing excellent and cost conscious care.

Host: Along those lines, Dr. Trambley, I have to ask you this. As an exercise physiologist for internal medicine providers, are they getting any exercise physiology or nutrition as a part of whether they're working with heart failure patients or stroke or diabetes or any of these things where diet and nutrition can be aptly served by the internal medicine provider?

Dr. Trambley:   It depends a little bit exactly how you look at that. So there are places where some parts of physiology in terms of pulmonary physiology or maybe rehabilitation physiology that are part of things that we know work. So cardiac rehabilitation and some of the exercise or physiology around that, how do we get patients after a heart problem to be active but healthy and safe while they're active? Build up their strength and exertion again. Some of those things are among the proven things that we are trying to implement. So the residents won't necessarily be the people who understand what is the latest in exercise physiology because that’s something another professional has an expertise in. They’ll learn something about it, but it will be important for them to know that it works and when it is something that’s appropriate for their patient either in the hospital or on discharge.

In nutrition, there is definitely teaching about nutrition in medical school. In the hospital, we’ve learned a lot about how to keep up nutrition and health in our patients. So for inpatients, things like when to use enteral feeds, when to use supplements, when to use what we call total parenteral nutrition—which is nutrition given IV. We've learned a lot about and we expert our residents to learn and implement that. There was a time where people didn’t pay attention to whether hospital patients were eating or not or getting nutrition. We know that that’s something that we need to be better at. So they're not going to be nutritionist. There are still other professionals who do a lot of that, but they know about it and they know what packages of interventions or what order and things we do in the hospital to optimize patient status in those areas in the hospital and then as they're being discharged.

Host: What an excellent way to put it. Thank you so much, Dr. Trambley. So as we wrap up, give us some of the unique attributes of your program and what’s it like at TVH? Tell us about the faculty and the instructors.

Dr. Trambley:   As a new program, I think one of the best things about our faculty and instructors is enthusiasm. There were many people who wanted to have trainees here. Who have some to Temecula Valley from great training programs themselves either as trainees or teachers or both who really thought that this was a place that could do that. They are just thrilled to have residents with them and excited to teach. I think one of the major things we are offering as a group that is with Temecula Valley and their parent company UHS is a focus on how medicine really works in this area. We feel that if we are going to train physicians and ask them to stay here, they should really know what it means to be a doctor here. So we really try to talk to them about how to do excellent care, what that takes. When we send them to a rotation with outpatient components, we want them to really feel like they're getting the experience of what would it be like to be a primary care doctor in this area? What are the goods, what are the bads, and how do I make this a great life for me?

That’s something you don’t get oftentimes in some programs where the goal is not to keep you here, but to have you go on to further training and possibly to work at great institutions. What I tell some of my residents or some of our applicants is at other places where I've worked, if I was the residency program director, the best thing in the world would be for all of my residents to be further training and faculty some day at places like Harvard or University of California San Francisco or UCSD or a place like that because that would look great. Our job here at this Southern California Medical Education consortium is to keep our residents. So we really focus on what’s it gonna mean, what’s it gonna take to have you want to stay in this area and be a part of uplifting healthcare in this area.

Host: What a great point and what an excellent program. Do you have any final thoughts? What you would like to let the community at large know about the consortium, know about the residency program in internal medicine that’s being housed at Temecula Valley Hospital?

Dr. Trambley:   I would just say for the community that we are trying to serve that the best thing they can do is understand yes. There are doctors here and they are physicians already. They're just training in specialty who are physicians in training. So some people don’t like that. Some people are like, “I want a fully trained doctor.” They are always working with fully trained doctors. They often have more time to spend as they learn than some of the fully trained doctors, and that the goal of this is really to bring better healthcare to these communities. So we ask them to work with our residents, be patient with our residents as we grow into this program because in the end, these programs are gonna benefit the whole community. We hope in the next few years as we continue to grow and make connections with other groups that we can really make it so that people don’t have to leave the area to go get advanced healthcare. That they can stay in their homes, they can be where they are, and we’ll have what they need right here.

Host: How true and thank you so much, Dr. Trambley, for joining us today and telling us about the GME program in internal medicine. That wraps up this episode of TVH Healthchat with Temecula Valley Hospital. Head on over to our website at temeculavalleyhospital.com for more information on the GME programs and to get connected with one of our providers. If you found this podcast as informative as I did, please share with your friends and families so that they understand what these residents go through and they understand the quality of care that you’re getting from Temecula Valley Hospital and these programs. Don’t forget to check out all the other interest podcasts in our library.

Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Until next time, this is Melanie Cole.