George and Linda Plotzke were headed home to Chicago from a trip to the Atlantic Coast last month when Linda came down with pneumonia and horrible back pain. After two nearly sleepless nights, and an excruciating drive through upstate New York, the couple felt they had no choice but to stop in the emergency room at Buffalo General Medical Center.
“This was the first health scare we’ve had,” said Linda Plotzke, a retired special education teacher.
An X-ray, CT scan and admission to the 457-bed hospital followed as staff looked to lock on to the cause, and best treatment, for her symptoms.
“Everyone identified themselves along the way, and it was quite obvious I was not just in the care of a doctor but a team,” she said. “That made me feel a lot better.”
The approach was by design. Nurses, aides, medical students and veteran physicians all had a hand in her care – along with two other kinds of health professionals unique to communities that have medical schools: residents and fellows.
Western New York is better off because of these health care workers, although where they came from, how they got here, and the work they do is not completely understood, said Dr. Roseanne Berger and other physicians in the region.
Berger is senior associate dean for graduate medical education in the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, which trains residents and fellows.
Here’s a closer look at what they do.
WHERE THEY CAME FROM
All 801 residents and fellows in Western New York are doctors-in-training in settings tied to Berger’s department. They work in eight hospitals: Buffalo General, Women & Children’s, Millard Fillmore Suburban, Erie County Medical Center, Mercy, Sisters of Charity, Roswell Park Cancer Institute and the Buffalo Veterans Affairs Medical Center. You will also find them in dozens of clinics and medical office practices in Erie, Niagara and Cattaraugus counties.
They hail from 39 countries around the world. Each graduated from medical school and, as a result, is an MD.
The Internal Medicine Residency Program – the largest of 64 accredited UB residency and fellowship programs, with about 125 students – accepts 33 new doctors each year from among roughly 4,000 applicants.
In recent years, about one-third of those accepted into the three-year internal medicine program are U.S. citizens. Another third are Canadian and the last third come from other nations, said Dr. Christopher Schaeffer, program director.
"Our American system of graduate medical education is looked at as the gold standard worldwide," Schaeffer said, "so having a training program will bring the best and brightest from around the world to Buffalo. Some of those folks are going to return home, some are going to move to other jobs across the United States and some are going to stay right here.
"If you have ties here, you're more likely to stay in practice here," he said. "The program makes an investment in their training and we do hope some of the graduates decide to stay. We know that they do."
Jason Edwards is among the locals. Edwards, 28, graduated from Niagara Catholic High School, and earned his biology and medical degrees from UB. He is in his first year of residency and looks to work long-term in Western New York hospital-based care.
Michael Perras, also 28, is among those from outside the country. The Oakville, Ont. native is a second-year resident with a bachelor’s in biology from the University of Western Ontario in London, Ont., and medical degree from St. George’s University in Grenada. It’s where his uncle, Dr. Jamie Johnston, went to medical school in the 1980s before serving his residency in Buffalo and returning to Canada as a cardiologist.
“Going to a Caribbean school wasn’t my first choice for medical school,” Perras said. “I would have loved to have stayed in Canada, but I saw he was successful.” Perras visited Buffalo during his residency application process and like the faculty, residents and city vibe. “It’s also extremely close to home, which is a huge draw,” he said.
Residencies run from three to seven years, depending on the nature of the specialty they pursue. Cardiologists, gastroenterologists and neurosurgeons are among those who take the longer road.
Fellows spend at least an additional year digging deeper into a subspecialty.
Dr. Tyler Kent, an orthopedic surgeon, started a UB-sponsored upper extremity fellowship in August that trains three fellows annually, under the direction of Dr. Robert Ablove, of hand surgery at UBMD Orthopaedics and Sports Medicine and a medical school faculty member. The fellowship provides clinical training in a variety of sites, including ECMC, Kaleida Health, Excelsior Orthopaedics & Sports Medicine in Amherst, UBMD Orthopaedics and Sports Medicine and a new site at the Buffalo VA to provide care to local veterans.
The 32-year-old Chicago native holds a bachelor’s in biology from Colorado State University. He came to Buffalo for medical school and has stayed for his 5-year residency and yearlong fellowship – a 10-year commitment. He, his wife and 2-year-old son live in Kenmore.
Kent works with four doctors while at Excelsior, including Drs. James Kelly and Kory Reed, both hand and shoulder specialists who stayed in Western New York after similar fellowships working with the same practice.
“I thought this would be a fun place to come and hang out for one year and do my fellowship. That was 25 years ago,” said Kelly, who has extended family in the region. Kelly, 58, grew up in Scranton, Pa. and got most of his medical training in Philadelphia and Erie, Pa.; Reed, 36, from Rochester, also attended medical school and did his residency in Buffalo. Both are UB medical school faculty members.
"Fellows are physicians in training," Kelly said. "It's part of the training program but it's the last part. They could be working on their own."
HOW THEY GOT HERE
Residents have completed four years as college undergraduates and another four years in medical school before they start their first year, called an internship year. By the time new residents started this year, they had a median student loan debt of $207,000, according to lendedu.com.
In the third and fourth years of medical school, students rotate through a number of medical specialties to gain basic knowledge and skills in all of them. These students also spend time in hospitals and medical offices, taking patient histories and studying alongside doctors. “It’s a time for them to test out different careers and try to envision focusing on one area versus another,” Berger said.
Toward the end medical school, students apply for residencies in specialties that include family medicine, ophthalmology, pediatrics and dozens of others. The UB dental school also offers three residency programs. Students often apply to 20 or more medical institutions across the country, and rank their preferences. Medical schools, including UB, set up small committees made up of physician specialists on faculty who help rank student preferences for the schools, as well.
An electronic matching system merges preference lists from students across the globe and schools nationwide, tilting a bit more toward applicant preferences, and all graduating medical students find out on the same day – Match Day – in mid-March where they will do their residencies.
Medical schools consider much more than grades, Berger said. In fact, some medical schools have turned to a pass/fail grading system or list class rankings.
All student applicants must take a standardized U.S. Medical Licensing Exam as part of the process, and programs can look at results. Applicants also are asked to write a personal statement that includes information about volunteer work, unique talents, and past hardships overcome.
“More and more, including at our medical school, there’s holistic review,” Berger said. … If you just focus on a grade, you may get a super smart person who doesn't have any of the other characteristics that are really essential for being a clinician. Those are not easily measurable by grades."
WHAT COMES NEXT
Residencies and fellowships vary in popularity. Some are very small. There may only be a few hundred slots in the nation for pediatric surgery, Berger said, compared to thousands for general internal medicine.
“In Buffalo, we have opportunities for residents to train in medicine in multiple hospitals,” Berger said. “They’re often on the front lines of intensive care units, critical care units. One of the things about an academic medical center that is different from a non-teaching center is they provide specialized services other places might not, things like intensive care nurseries, burn units, transplant services, stroke centers. These are the kinds of things that do not function outside an academic medical center, so we’re really lucky in Buffalo to have those. Otherwise, we’d be transferring all of the people with these issues to Rochester and Cleveland.”
Berger had two residencies herself, one at the former Deaconess Hospital in Buffalo and another at University Hospital in San Diego. She followed them up with a fellowship in geriatrics with UB.
The physician, also an associate professor of clinical family medicine at UB, spends most of her professional life at the university but also works one day a week at UBMD Family Medicine in Amherst.”
“My patients enjoy teaching the students,” she said. “They tell their stories and feel like they’re contributing. They feel that because I am teaching students, I must be providing up-to-date care. If you’re teaching students, they will ask you challenging questions, you’ll be going to the literature and reading. You’ll be posing questions of the students. I think it keeps people on their toes.”
Residencies are an expected part of a medical education, Berger said, while fellowships are reserved for those who need more specialized training.
“All medical students must do post-graduate training in order to sit for a specialty board, a very rigorous exam that follows post-graduate training,” she said. “Once you’re in practice, there are recertification exams to make sure doctors are keeping up with their level of expertise. In today’s world of medicine, you need that specialty board to practice in a hospital, and to be enrolled as a provider in an insurance company.”
Residents go to work in hospitals, hospital clinics and medical offices under the supervision of practicing doctors who must be affiliated with a medical training institution. The UB graduate medicine program touts 782 full-time and 1,174 volunteer faculty members.
Why do so many doctors teach for free? “I think physicians find it inherently rewarding to teach and prepare the next generation,” Berger said.
Residents wear plastic badges with their names and photos. Their lab coats include UB insignia – and, because they are doctors, their lab coats are as long as doctors and fellows, stretching below the knee. Medical students wear shorter lab coats.
“You’re likely to have a resident involved from the very beginning of your care in a teaching hospital or other teaching setting,” Berger said. “They most likely would be involved in almost every aspect of your care under the supervision of your attending physician. What that brings to the table is that you have more clinicians who are supervising your care and involved in paying attention to the details.”
Residents see patients on their own as part of the overall process – and can be the primary providers for a small number of patients in clinical settings. Edwards does so at UBMD Internal Medicine @ ECMC ; Perras at UBMD Internal Medicine @Hertel-Elmwood.
Residents may work up to 80 hours a week. They must take at least one day off after working up to seven consecutive days and can’t work more than 24 consecutive hours at a time.
They receive health insurance and get paid, $50,000 to $58,000 a year in this region, a bargain considering their important place in the regional medical system. Their salary and benefits are covered through a combination of Medicare, the VA and, to a smaller extent, Medicaid, Berger said. Hospitals and some practices, including Excelsior, also invest in the cost of training residents and fellows.
“You have to realize these residents are in their late 20s to mid-30s. They’re adults,” Reed said. “They need to move on with their lives. Many are married and have families to support. Most have debt from medical school.”
Fellows generally are paid a bit more and get a better glimpse into the management of a practice and a deeper dive into their specialty.
Kent and other fellows who have cycled through the Excelsior practice look to Reed and Dr. Timothy McGrath to learn more about total shoulder replacements, to Dr. John Callahan, a hand trauma expert, and Kelly, who subspecializes in pediatric orthopedics, including congenital issues of the hand.
"We're providing a very rich selection of cases that these doctors can learn from," Reed said.
Fellows sit in on confidential weekly case discussions at the practice. It's also common for former fellows to check in with their former teachers to discuss complex cases – and sometimes vice-versa.
"A surgeon operates with a team of colleagues, and a patient doesn't always see that team of colleagues," Reed said, "but if you knew that they were there, wouldn't it be reassuring?"
If patients are introduced to a fellow during an office visit, "that should be something that impresses them because that place trains fellows," Kelly said. "Not everybody does. It has to be a cutting-edge practice."
Edwards, the resident who works at Buffalo General and the ECMC clinic, as well as the VA, generally introduces himself to patients and their families as Dr. Edwards, then tells them he is a resident. “You’re both of those things,” the Niagara Falls native said.
He and other residents often are the first doctors to ask patients about health history and current health challenges. They can diagnose an illness or condition, and prescribe a course of treatment – including medication.
"When we're young and in training, you get great care from a resident because they care so much," Edwards said. "They're looking at every detail. They haven't seen it a million times so everything they see fills them with some wonderment."
Residents routinely confer about cases with other residents, fellows and doctors.
“You can spend a pretty significant time by yourself with a patient and family getting to know them,” Edwards said, “but you always have a net under you.”
Edwards and Perras are among who work four-week rotations, spending most of that time working shifts at Buffalo General – including the critical and intensive care units – and about one week in clinic. One reason their shifts can get long: “You don’t leave a patient who’s not stable,” Edwards said.
Kent, the orthopedic fellow, no longer works 80 hours a week. “It’s much more family friendly and experience-wise, there’s a focus on what you want to get out of it.” He can focus on particular surgeries – in which he can assist but not yet lead – hone his bedside manner in preparation for the types of cases he one day will handle on his own, and get a greater feel for what goes into helping to run a medical practice. He also sees more of his own patients than he did as a resident.
“Most of the patients are very receptive,” Kent said. “They know that Excelsior is a teaching facility and they expect to have students and fellows in the room. Some are concerned that the attending physician will not be present during the surgical proceeding but that is never the case.”
IMPACT ON PATIENTS
Residents and fellows add value to patients, physician offices and hospitals, Schaeffer said.
“One way is the energy and enthusiasm of the team when you have a whole range of different knowledge and experience,” he said. Their energy and enthusiasm for trying new and improved ways of doing things is helpful. … Another part is that as Buffalo is becoming a more diverse community, we bring residents from countries who are native speakers and who understand the native cultures of a lot of our refugee and immigrant communities.”
The team formula was a welcome experience in the middle of a frightening experience for the Plotzkes, both 70, who have spent the last two years traveling frequently during retirement. At first, the Chicago couple were skeptical of the diagnosis Linda Plotzke received. Buffalo General doctors concluded she probably was suffering from Lyme disease – a diagnosis that will take another couple of weeks to confirm through testing. The more Linda Plotzke learned from the medical staff, the better she felt about the diagnosis and treatment plan. She was given antibiotics and a limited amount of pain medication. The staff also reached out to her doctor in Chicago to help make continuing treatment seamless.
“I’ve been very impressed,” she said as she was being discharged 3½ days after her arrival. “I feel 100 times better. The care has been wonderful. I cannot say enough. Everyone communicated with me and each other. All along the way, I saw thoughtful people who were trying to do the right thing.”
Twitter: @BNrefresh, @ScottBScanlon