Schooled in Suspicion? How Medical Education Contributes to a "Silo" Mentality

There's an urgent need today for better integration in healthcare. Unfortunately, training and practice haven't quite caught up with reality.

Suddenly we're asking hospitalists and ED physicians to team up in ways they never imagined. We're asking them to think with one mind and act as part of an integrated team when they've been conditioned from medical school to side with their respective specialty's interests and to view each other with suspicion.

The concept of professional "silos" — and the barriers to change they present — have been on my mind lately. A few months ago, the hospitalists at one of the facilities I work at opted to join Vituity as Partners. Since we'd been striving for greater integration, I was thrilled by the news.

I'll admit part of me secretly hoped that uniting us under one organizational structure would work miracles. However, fostering trust and communication between our teams has been far more challenging than I anticipated. Even matters as simple as finding common times when we could all attend meetings and social events has been a challenge, but even more challenging has been working toward a common culture.

Whenever I catch myself wondering why we can't all just put our differences aside, I think back to my first clinical rotations in medical school. As medical students, we gravitate toward specialties that fit our personalities and preferences, and these traits are further refined and hardwired into us as we advance through residency and practice. It is at this point that "battle lines" get drawn between specialties.

As a third-year medical student completing my ED rotation, I absorbed professional politics along with suturing and airway management. What can we say to the internist that will convince them to admit our patient? The question colored many conversations with senior residents and attendings. It wasn't that we set out to deceive anyone, but for whatever reason, we truly felt that this patient shouldn't go home. I was trained to expect to face resistance on that phone call.

However, while rotating on the internal medicine service, I observed the same interaction from the other side of the phone line. When the resident's pager went off and the call was to the ER for an admission, you could practically see the wheels turning. How do I convince them that this patient doesn't need to be admitted? How do I show them he really is safe to go home?

This divide, which gets set up from the earliest phases of clinical training, is unfortunate. Creating a sense of shared mission between the ED and inpatient care areas is critically important to the future of hospitals and patients. But this deep-rooted "mine" and "yours" mentality gets in the way of trust. And it's trust that lays the foundation for strong, meaningful integration.

There's certainly been some movement in the right direction. The emergence of hospital medicine as a specialty was a tremendous step forward. It's far easier and more expedient to arrange an admission at 2 a.m. with a physician dedicated to the care of hospitalized patients than with a primary care physician who faces a full-office schedule the next day. Under the new system, our patients receive more and more timely attention on the inpatient service.

A paradigm shift is occurring in medical education as well. Medical schools and residency programs are beginning to emphasize teaming and interprofessional skills, which tomorrow's physicians will hopefully carry into practice. As I mentioned above, when I went on rounds on the wards, it did wonders for my understanding of how the hospitalists approached patient care differently than we in the ED did.

Maybe in the future, some forward-thinking medical school or residency program will create a brand new specialty that combines emergency and hospital medicine. These "acute care physicians" would follow their patients across the continuum from the ED to the inpatient floor; and professional "silos" — and the protectionism they foster — would disappear from the equation.