In the latest installment of our Program Director Interview Series, we spoke with Madonna Fernandez-Frackelton, MD, FACEP, program director at the Harbor-UCLA Medical Center Emergency Medicine Residency in Torrance, CA, about what makes her program unique and what type of residents get attracted to this county setting.
What makes working in a county department special? What type of learners would this environment attract?
I kind of grew up in the county and love this patient population. What I really love about it is that our patients really have limited access to care, and often don't have other places to go. We are really fortunate in our department to not only have the resources but a team that is committed to serving this patient population longitudinally. So, not only their emergent issues but also dealing with longitudinal care making sure they're plugged in with primary care to hopefully prevent further ED visits if necessary.
The people that we really are trying to attract are those who want to work with an underserved patient population and know that it is in a county setting. Although a lot of counties have limited resources, we've actually been very fortunate in that we've obtained some state grants and we have been able to initiate a lot of programs and help residents with initiating those programs to help our patient population. I did actually work in the community for a few years after residency. Um, and it was fun. It was great, but it was just definitely not as satisfying as working with our patient population, so I came back.
Given the wide range of specialties at Harbor/UCLA, can you please comment on the level of independence in medical decision-making among EM residents, and how often they consult other services?
We are very fortunate that we have a lot of other specialties available to us at Harbor. You'll hear a lot of people say we're the strongest program in the hospital, and I do think that's true. I'm a little biased, but we are fortunate to have a lot of other really strong specialties in the hospital. We also have a culture of completing a thorough investigation and workup before we consult our colleagues and really make sure that we have a specific question to ask otherwise we generally don't call them. During our orientations, we have a mock consultation prep where we ask interns “what is your question?” We instill in our residents that you don’t call a consultant unless you have a specific question. The specialists that rotate here, especially the surgical sub-specialists, also rotate at multiple sites and they often comment on how thorough and thoughtful our consultations are.
That said, with all of the affordable care act and the empanelment of patients, a significant number of our patients that show up in the ED are not impaneled to our system. This makes it so we really don't consult. For example, if someone comes in with a distal radius fracture that is not empaneled to our providers and is not going to follow up with our orthopedists, we do the reduction splint and send them out to get their ortho referral. So, it varies kind of empanelment to empanelment if we get consultations or not. In general, we really try to minimize utilizing that resource and make a decision with the consultant, if it's necessary.
What type of applicant do you think would thrive at Harbor? What type of applicant do you think would struggle there?
In the county environment, the people that thrive here and choose to come here are very self-motivated and self-starters. Our hospital is pretty much resident-run– every patient is seen by a resident. It's not like you're working in parallel with a faculty member and they're seeing their patients and then you present patients to them. Rather, every single patient in the department is seen by a resident. This makes it so it's really on the resident to be self-motivated to pick up the number of patients, to go to the bedside of those critical patients, and to be kind of be active in their own learning. I think the people that don't thrive in this environment are those who really need encouragement to be self-motivated and to push themselves. I also think people who want to look at an underserved population do well here. People who might have only worked at a private facility and not had an experience in the county hospital, uh, sometimes come in and have their eyes wide open when they hit the door.
How does your program uniquely prepare residents for attaining future jobs and careers in Emergency Medicine?
Part of our curriculum also involves rotations at community hospitals. Sometimes those are audition rotations. Those hospitals often actually hire our graduates. But we generally prepare people by giving them an excellent clinical experience and then also have a pretty vast network of alumni throughout the country, and throughout the world. A lot of our alumni are directors of departments, program directors, chairs, et cetera. So when they're looking to hire people, they're often looking for our grads because they know they're, well-trained, they know they're going to get along well with their nursing staff. It's another thing that we really instill in the residents and think is an important part of working together as a team.
We also have retreats for every class each year. The one for the fourth-year class is before we send them to ACEP. For this retreat, we actually bring in directors of various EM groups and talk about contract negotiations and teach them what they need to look for when they're going out, seeking a job before they sign a contract. All of those leaders of the EM groups are also our graduates. So, they come in and kind of teach them what they need to look for when they are looking for a job.
Last year was a tough job market for emergency medicine. During the middle of the COVID pandemic, hospitals were cutting staff. A lot of program directors were in situations where their graduates were having a hard time finding jobs, and in that setting, every single one of our graduates last year left the program with a job. So we were really fortunate.
Your program has numerous social EM projects, to name a few: Whole person care projects, homeless health & street medicine electives, food pharmacy, immigration/safe spaces, etc.
Who created them and how are residents involved?
The best part about all of these programs is that they were really resident-initiated. Residents paired up with a faculty mentor and then kind of started a committee so that they made sure that the residents in each class continued to be involved in these projects. Some projects involved writing grants, and then they hit the ground running and basically initiated these programs.
I’m a big fan of the food pharmacy. The food pharmacy is fantastic because it's a really simple initiative that doesn't involve any sort of insurance. You don't have to go through any paperwork. Any patient can qualify, whether they're a county patient or not, we just provide them the information. Every Wednesday they line up and get some healthy food that hopefully will initiate better eating habits and help them with their hypertension and diabetes.
Do you think this is part of the culture of Harbor-UCLA?
Yes it’s definitely part of the culture of Harbor. In the past we would team up with family medicine. They have done a lot of community outreach. Trauma has also always been involved in some sort of community outreach and preventative programs. So we've kind of always been involved with them. One thing that family medicine is doing that is fantastic includes Gloria Sanchez, who is one of the associate program directors for the family medicine program. Well, she is also an addiction specialist, and she started a medically assisted treatment team consult. This allows for where we can actually consult them during the day to come talk to our patients who are having substance use disorder.
Can you share with us a little bit about the trauma recovery center and how this came about to be and the involvement of emergency medicine residents?
The trauma recovery center is also a collaborative effort that was really adopted by hospital administration. It was an effort between the ED, trauma team, social work, and psychiatry, based on the fact that we see all of these victims of violent crimes, gang violence, a lot of recidivism in that patient population. It’s kind of like this revolving door of violent crime, ER visit, violent crime, ER visit. We wanted a way to deal with the emotional fallout from that as well as try to help people integrate back into a normal lifestyle.
With the joint effort between all four departments to address not just the victims of violent crime, but interestingly, it’s also for the family members. So, if you think about the 14-year-old child who was shot, the parents of that child also have some significant trauma that needs to be addressed as well. This makes it so anyone can be referred. And the resident involvement is through the socially EM-required rotation that they have. It’s incorporated where they will do shifts. They're also involved in the process to get patients assigned to get into the trauma recovery center. So when we have a trauma, there's like an automatic page that goes out to the social worker who initiates a consultation to determine if this was an interpersonal violence situation. Then the social worker follows them through their course in the hospital, as well as makes sure they get referred to the trauma recovery center, makes appointments, calls, and follows up if they don't show up. This allows for a really continued follow-through.
With the COVID-19 pandemic enduring its second year, I imagine the department may look a little different. What are recent changes to the program structure or curriculum that have been made?
Generally, the curriculum changes every year a little bit. As far as COVID goes, there wasn't much that changed with the curriculum. One of the things we did when we had the wave in January was that we pulled residents off of our outside rotation at Cedars-Sinai medical ICU just for one week at a time to help come back and help staff our medical ICU team. So they still got critical care– there were a lot of really sick patients, a lot of intubations, a lot of lines, et cetera. The difference is it was just here at Harbor rather than at an outside facility. We made this a temporary thing. We really tried to minimize the effect it had on the overall curriculum by just pulling people back one week at a time. We wanted to make sure they still had that experience with their outside rotation.
Another thing is that we also staffed a surge team. Our new ED is composed of all respiratory isolation beds. There are only 11 respiratory isolation ICU beds in the hospital, and there are 92 respiratory isolation beds in the emergency department. And so, our COVID plan was that we became the defacto additional ICU and it filled up half of the ED at the peak of the pandemic. What we had to do was not only help staff those – going from one medical ICU team to five, but we also staffed an additional team where we were seeing people in the hallways with like curtains dividers between them. I think the really important component of that is that when we staff these additional surge teams, we didn't just put a bunch of residents on a search team. All the faculty took shifts. Basically, everyone did a little extra work to staff those teams. That was the primary effect briefly. Overall, it hasn't really affected our department or our curriculum. The one good thing that did come out of it is that our ED has one area that was an observation area ranked by medicine and during the pandemic it became an ICU. And then as we eased back into that area, we actually were able to take it over and keep it. We now actually have more space in the ED than we had before. So, we're hoping to still keep it moving forward.
Then the other thing I think that has happened that has changed is more of a national issue. There’s a national nursing shortage. The pandemic made that more obvious and has contributed to some of it. With our hospital implementing a vaccination requirement, it has shifted for some reason that is inexplicable to me. Nurses are a group of people, including nurses and firefighters that are not highly vaccinated as the physicians. Some of them have retired early and that has affected the department overall. We've been really lucky because it's a really fun place to work. So, we still do get a lot of really new nurses right out of school who want to come in and experience the county. So, so far we're managing with that shortage, but it is something that I think will long-term affect a lot of people. In my last couple of shifts, I was on the first shift where they said there's going to be a shortage because they implemented the vaccine mandate. And they knew that they were going to have nurses transferred to non-clinical areas. The ops team had actually hired enough travelers that I didn't even notice my entire shift. In general, some shifts are worse than others. When there’s a shortage, we ended up closing some beds. It's unfortunate. It results in some longer waiting times, but we just have to be vigilant about combing the waiting room and making sure no one has really sick out there.
Could you describe the culture and relationship that residents and faculty have with each other?
One of the reasons I came here 25 years ago as a medical student is the relationship that the residents have with each other and with the faculty. I loved it. It’s always been a very supportive collegial relationship resident to resident. And I noticed this having rotated at a couple of different places. I'll never forget this when I was rotating at another place that I won't mention, one of the residents got sick. She was actually diagnosed with Lupus and at that facility, her co-residents who had to cover for her for shifts and doctor's appointments were complaining. And I was like thinking to myself, well, she's not like she's having fun. This was just kind of a little off-putting to me.
Then I actually came to Harbor and something similar happened, not as severe, but someone had broken their wrist and was in a cast and couldn't do simple procedures. However, everyone was like bending over backward and tripping over each other to help and say, “Hey, don't worry about it”. And I just said, okay, that's the place I want to be. Everyone was really supportive. This type of environment continues today. The classes are big enough that you can find someone with similar interests. There are 16 per class, but they're small enough that everyone knows everyone. We have buddy groups and socialize together. Now that we're back in conference sessions, we've started again with beach volleyball after conferences. I am not a beach volleyball player, but there are a group of people that do that. So it is a very collegial relationship.
As far as between residents and faculty, residents are all on a first-name basis with the faculty. Sometimes it takes them a year to actually get to that point, but everyone is on a first-name basis.
We also have a really good relationship with the other services as well. I've taught my residents this too: if someone comes, for example, if a surgery consult comes in and they're really angry and they say something totally inappropriate and they storm out (I've done this a number of times) I'll go after them. And I'm like, “are you okay?” And then it's totally disarming. They've just lost someone in the operating room or such. You know, it's really important, to be aware of what someone else's going through. And if people are behaving badly, there's probably a reason… they're stressed, they're tired, they just lost a patient, something. So rather than reacting and calling them out on it, just ask if they're okay. It's kind of disarming. And I think that has contributed to really good relationships between the residents on all the other services as well.
What structures are in place to promote resident wellness?
We actually have a number of things. The graduate medical education office hired a psychologist specifically for the residents. She comes and meets with each of the classes in each of the training programs in the hospital. She comes twice a year to our conference to make sure everyone's aware of those mental health resources that we have available. Obviously, we hope that people don't get the point that they need that. We have our buddy groups that have a network of peers and faculty that the residents can go to if they have any issues. We also do class weekends. I have a big enough program that when I make the schedule, I can give all the PGY-4s the weekend off together, all the PGY-3s a weekend off together. So it's something that they look forward to.
Then little things… we buy food for our rounds room, the doc boxes, ensuring that there are snacks throughout your shift. We have an exercise room. I actually got rid of the old storage closet, which was full of files that we're scanning and digitalizing. We transformed it by putting a TV in there, a Peloton, exercise equipment, and a massage chair. A couple of my residents are notorious for every time I walk by, they’re sitting in the massage chair. We have a chili cook-off that is now in its third year. Overall, lots of different things just to kind of make sure that people are doing real-life stuff, not just medicine.