From RN to MD: Two Ascension Seton Perspectives

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When the inaugural class of 50 students gathers in July at The University of Texas at Austin’s Dell Medical School, it will include one of Seton’s own – David J. Woerner, RN, CNA.

David’s is not the usual career path for an aspiring physician. It’s uncommon for a registered nurse pursue a medical degree. Woerner, 30, who works in the orthopedic/trauma/reconstructive plastic surgery unit on the eighth floor at University Medical Center Brackenridge, will be one of only two RNs in his class.RN to MD PIC1

But at Ascension Seton, he follows in someone else’s footsteps. Mark Hernandez, MD, RN is chief medical officer of the Community Care Collaborative, a Ascension Seton partnership with Central Health, Travis County’s health care district. Before earning his medical degree, Hernandez worked as a registered nurse for six years.

Recently, Woerner and Hernandez met for the first time at Central Health.

Mark Hernandez: First of all, congratulations.

David Woerner: Thank you so much. Did you work at Brackenridge? Everyone on the eighth floor asked me, ‘Do you know Mark Hernandez? He was a nurse, too.’

MH: My whole nursing career was spent in Houston. I worked as a nurse while I was in medical school. I needed the money, so I kept pulling weekend shifts and some Friday nights.

DW: Wow.

MH: I worked in fits and starts. At times, I’d do five or six shifts in a row, and then they wouldn’t see me for two months. I did that for four years of medical school.

DW: I’m probably going to take the first six months (of classes and not work) and get my pace down. But especially in December, when we have breaks, I hope to pick up some overtime or two weeks, then take a vacation. One shift here and there isn’t really bad.

MH: Well, you won’t do anything for a while. What you can’t predict is where your life will go. You can do a lot of work trying to plan that, but it won’t turn out the way you expected it to. You probably won’t practice as a nurse again, but it remains valuable for different reasons. I think back to early nights at Brackenridge as an intern, when I met all the nurses on the seventh and eighth floors and it rapidly become known that I was a nurse. I didn’t walk around and tell anybody, but my resident colleagues opened their mouths a lot. They also would often pull me into rooms to start IVs and things like that.

DW: (laughs)

‘Immeasurably Better’

Seton.net: So it was an advantage for you to be seen as one of the nurses?

MH: It made my life in the hospital immeasurably better in that the nurses viewed me as one of them. It shouldn’t be. We shouldn’t still have a world with an ‘us vs. them’ dichotomy between doctors and nurses.

DW: Yes, we absolutely do, and I’ve been in hospitals for 14 years, so I know.

MH: The nurses took care of me to a large degree and ensured my residency experience was much better than it might have been. You’ll also discover that you understand health care in ways that your medical school colleagues won’t. That’s not to say you won’t have some uniquely experienced people in your class, because you will.

DW: And we do. Dell Medical School has done a lot to choose not only a diverse group of students with a wide range of experiences, but also people who, I believe, having met at least half, feel they have been selected for their interpersonal skills. They aren’t so introverted they can’t have a conversation with another human being.

MH: You’re going to walk into the hospital for the first day of rotations and get it. And what you’re going to find is there’s a very, very steep learning curve.

Students on clinical rotations go through this cycle. First, you have to learn to function in this environment. You’re asked to go pull the chart up or find these films or find the charge nurse and find out when this MRI will be done. So when you say this to someone with no conception as to how a hospital looks or who anyone is, it’s a very daunting task. And the system isn’t very forgiving of your inability to navigate it.

After that is figuring out, ‘What is my role as a student?’ Only once you’ve settled into that can you get around to, ‘How do I practice medicine?’

On Day One, you’re going to be like, yeah, this is a hospital – your hospital, in fact. You’ll know where the cafeteria is, where the restrooms are, how to open up a patient chart and navigate it. You may not know who the charge nurse is on, say, the sixth floor, but you will walk up there knowing you need to know who that person is and that it’s critical to your success.

Your colleagues will walk in and not know what hit them. I remember, as an intern, I’d sit in the clerk’s chair at night, writing my notes, and I’d also answer the phone. And I’d call out to the nurses someone needs this or that and the nurses appreciated it. Then I had a nurse tell me, don’t sit in this chair during the day, this is the day clerk’s chair during the day. If you do, your name will be mud during your time here at this hospital.

DW: (laughs)

MH: So I began to sit in the chair across from that chair and got to be very good friends with that clerk. Even as a hospital doctor, I never would sit in her chair.

DW: There’s a unique culture in a hospital, and having worked in one for so long, I really have a feel for it. Having been a CNA [certified nurse assistant], I know CNAs think a certain way. And having been a nurse for the past year and a half, I know nurses think a certain way. There’s this kind of camaraderie because they’re the front line staff. There’s a degree of intimacy that doesn’t occur at the physician level. You’re up in a patient’s personal space and personal business, which doctors find unusual.

As a medical student, I’m going to be recognizing people that I’ve seen, the attendings, surgical department, chiefs of the surgical services and others. Because hospital work is a lot about working with team members, whether it’s pharmacy or dietary people or other clinical staff, you have to have a good working relationship them.

Seton.net: Is that something you think needs to change in medical education?

DW: Definitely. Medical students don’t meet the nurses, really, during their medical education and it’s the nurses who are really carrying out everything that doctors prescribe in a hospital environment. Having an understanding of how nurses prioritize and carry out duties is a huge asset.

What is it Like?

Seton.net: What is it like to be in medical school as a nurse?

MH: You’ll get this question a lot. And I always tell them, I have never not been a nurse. I’ve always had a different view of health care – and you will, too. Be aware of that. Help other students understand that.

Having been a nurse, I had this much broader view of what health care delivery should be. Sometimes it gave me a leg up, but it did not necessarily give me a better view of what it is to be a patient.

What is the fundamental job of being a physician? The trick is: can you create the therapeutic relationship necessary, in the 20 or 25 minutes you’re given, to get your patient to go along with all the things you do to examine, diagnose and treat them? All your knowledge helps you put together a nice little plan, but can I get Steve to cooperate? That’s the practice of medicine.

DW: I feel like nursing is the same way. Physicians have less time to see patients, but I have 12 hours to see patients (during a shift) and I’ll see them again the next day. I have many opportunities to establish rapport with patients and I can build it quickly. A hospital room is a very comfortable place for me. Doctors can’t always get that opportunity, especially if I’m a physician who only does physical exams every fourth Friday of the month and I only see Medicaid patients every other third Friday. It’s harder to build trust with a patient, which is one of the reasons I want to go into primary care.

A large part of it is building relationships and helping patients navigate the health care system. I want to be flexible and available enough. My dad is a physician and he’ll see anyone, whenever. Sometimes the mark of a good clinic physician is wait times. They get behind near the end of a day because they’re taking the time they need to with patients. He lets people come in who aren’t quite getting the right result and just need a little tweaking.

The delivery of medicine really is an art, an apprenticeship. It’s like building a violin. You don’t go to school and learn how to build a violin. You learn from a master, then you tweak and tweak and tweak until you’re the master. I think medicine is the same way and nursing is the same way.

Hidden Curriculum: Getting to Value

Seton.net: It feels like David is entering medicine at one of the most exciting times. What do you think, doc?

MH: It’s an incredibly exciting time. The challenge is what we often call the hidden curriculum. It’s what you’re going to see, how health care is actually delivered outside of lectures and conversations like this one. For example, you talked about your dad’s waiting room times. Waiting rooms perpetuate a mismatch between a financial system and care delivery system.

Your dad comes to work every day committed to being the best doctor he can for every patient, so he needs to bring his ‘A game’ for all of them. Meanwhile, the financial system says he needs to see 22 patients today.

DW: I would think a physician should be compensated for reviewing patient charts. They only get paid a fee for service, what they actually do with the patient. Good health care, good preventative care means there’s a lot of sitting down and studying charts, learning more about who patients are, just like reviewing labs and making call backs and helping patients navigate the system.

MH: That’s part of the hidden curriculum. There’s constant tension between administration and the provider. How do we shorten the wait times? You can hire a midlevel provider and move some patients over, but a doctor may push back, saying, “patients want to see me.” But who are we trying to create value for?

This is a fundamental change – we’re having conversations now about value. You can make the system more efficient – that adds value. Or get better outcomes – that adds value. In an ideal world, you do both. But value for whom? What we’re beginning to discover is that we’ve long worked in a system for which the value has not been for the patient.

I can go home feeling good. I saw all my patients and gave them the time they needed. What I would challenge is, show me that their health outcomes were better because you spent half an hour with each of them instead of 20 minutes. Also, keep in mind your family’s outcome is worse because you came home two hours late and didn’t eat dinner with them. The office outcome is worse because staff had to work overtime. It made your patients feel worse while they were waiting. But show me that their outcomes were better. Is their diabetes better controlled?

Maybe the only thing they really needed from me is to stick my head in on my way to see another patient and say, “Mr. Smith, good to see you in the office. You follow the advice of this dietitian you’re talking to.” Because the dietitian is better at explaining how to better eat with your diabetes. That helps Mr. Smith go home and have a better outcome.

Fundamentally, the way health care will change is that we need to quit believing that the physician is the center of health care delivery.

DW: I absolutely agree with you.

‘What Do You Want?’

MH: We have failed to recognize that, if we deliver you the best care that you didn’t want, we’ve failed somewhere.

DW: I think we do often forget that. We forget to even ask, “What do you want?”

MH: By the way, nurses can be bad at that, too.

DW: No, we absolutely can be.

MH: ”Sir, could you just lay down on the bed, I need to check your blood pressure, just hang on, I have to get you in the bed and answer these questions” … and the patient wets the bed.

DW: We’re trying to get out on time, trying to get our days done, trying to get the meds taken. “I know you always take this medication with food so you don’t risk getting nauseous, but I’m going to give it to you now because now is when I have the time. I’ll treat your nausea later if I have to.”

MH: You need to connect to that person. Remember that’s why you came here to do this.

“Write yourself a mission statement for your medical career.”

Seton.net: So David, why do you now want to be a doctor?

DW: I’ve traveled a long path through health care. I’m looking at the whole system and my abilities and I’m trying to fit myself in. My high school job was in a hospital. In health care somewhere is my natural place. Where in health care? I was a C student in high school, but when I was a CNA, I met people who profoundly changed by view of my own abilities.

I decided to go back to school and become a nurse. A nurse has more autonomy, more authority to make decisions and in more ways can help people. I just began acing classes. I remember sitting in anatomy and identifying structures and everyone else in the class was confused. I was thinking, maybe I can do more, maybe I can take the next steps and be a physician.

I want to pursue my MPH in my third year (of medical school). I think you need to work at preventing ailments while understanding you will have people fall through the cracks.

MH: Write yourself a mission statement for your medical career. Right now, while you’re still unsullied by the process of becoming a doctor –

DW: (laughs)

MH: Write down what you want to achieve, in its purest state. Because you’re going to run into times when you’re pulled away, when you forget. The good news is you’re going to a medical school that knows you can’t keep students behind walls of this new building forever. Students have to go out and learn to take care of patients out there in the world. And out there, we’re not doing it right yet.

Central Health and the voters of Travis County are supporting the creation of Dell Medical School at The University of Texas at Austin. The Community Care Collaborative is developing an integrated health care delivery system for low income and uninsured members of the community.

More about Mark Hernandez, MD

Mark S. Hernandez, MD, is the chief medical officer for the Community Care Collaborative, a public/private partnership between Central Health and the Ascension Seton.

He worked as a registered nurse for 10 years in the intensive care department of Houston’s Ben Taub General Hospital. He graduated from the Baylor College of Medicine in 2003, performed his residency in internal medicine at University Medical Center Brackenridge in Austin, and became the medical director for the UMC Brackenridge hospitalist group in 2011. Hernandez assumed his current position in 2012. In addition, he holds academic appointments with the University of Texas Southwestern School of Medicine, the University of Texas Medical Branch, and is an adjunct faculty member with the University of Texas at Austin School of Nursing.

As chief medical officer for the Community Care Collaborative, Hernandez works with multiple clinicians and service organizations throughout Travis County to fulfill the goals of the Collaborative, which include transforming the delivery of care into an integrated system.