Hello all: I've been a long-time reader of SDN, and I thought I'd get some input on this dilemma. I'm a 4th year, somewhat disillusioned student at one of those 'big-name' programs in the Northeast. Consequently, I've spent the last year, and will spend this final year doing my required and elective rotations at huge academic medical centers.

I've learned a ton. I've done nothing. No blood draws. 1 IV. 2 ABGs. 5 NG tubes. 1 LP. I watched dozens of deliveries and caught the placenta for 5 (yeah I know, I'm going into IM so this doesn't really matter...). I'm not procedure-averse and I don't like being spoiled by a dedicated phlebotomy/IV/procedure/whatever team. I sincerely want to be proficient at these things. Am I ever going to be as good as the individual whose job it is to place IVs? Certainly not. Do I want to know how to put one in, even if it's a 'hard-stick', if that individual isn't around? Definitely. In fact, someday I'd like to spend a non-trivial fraction of my career working internationally, and then I won't have an IV team to page.

Sure, some might say that I'm just a medical student, and that I'll learn all these things during residency. But that is not necessarily what I've seen at these huge academic hospitals. And it's not just procedures, but also patient management. It's deciding what anti-hypertensive to give on the floor. Or how to work up this pancreatitis. Or whatever. Believe me, I love consulting the experts. I've done months on a consult service and it's fun. But for my residency, perhaps I want more autonomy. So here is where my dilemma arises.

Do I aim for a large urban county hospital, say for example USC LAC, Cook County, NYU Bellevue, Jackson Memorial Miami, where the patient volume is enormous, and ancillary services are less easily available, because I will get autonomy as a resident and learn by doing (which is what I prefer), while of course perhaps 'sacrificing' the 'best' (though that's questionable) didactics, research and fellowship opportunities, and venerable ranking?

Or do I stick with a big academic hospital, well ranked, good fellowship matching potential, 'good' didactics, and perhaps sacrifice autonomy?

Is it possible to have both?

I'm not posting this to compare the merits of specific hospitals and programs. I simply want to know what is a good training environment for an IM resident who learns by doing, but also isn't limiting for opportunities later. I've been to my share of teaching conferences and didactics. Morning report, senior report, noon conference, afternoon conference, junior report, attending report, attending conference, sign out conference, teaching seminar, physical sign rounds, and dozens more. Part of me loves that stuff. But another part of me says, you know what, I'll take a little hit on the didactic teaching end of things if I actually get to manage my own patients without having to consult on everything or needing a senior resident backup lurking in the call room during my call nights.

What do you think? I appreciate any thoughts.

I can certainly understand where you're coming from, having just gone through the process of finding that residency program that is the best for your individual wants/needs.
I understand that there is a desire to become competent performing basic procedures. To some level, I think we all have that want - even though we're internists and not procedure-based specialists, we should be as competent as the next physician when it comes to performing these sort of minor procedures.
That said, I personally would not want to go to a residency "where the patient volume is enormous, and ancillary services are less easily available, because I will get autonomy as a resident" as you put it. If you go to any university program with a VA hospital, you will be doing plenty of these minor procedures and by the end of your 3 years, you will be competent at them. As an intern/resident, there is MUCH more going on in your life - things that you cannot appreciate as a med student, and you don't want to have your life further complicated by having too high a patient load and doing busywork all the time. As a med student, I never fully appreciated all the demands that are placed on interns UNTIL I ACTUALLY STARTED RESIDENCY - now, I am very glad that my program has certain regulations in place to minimize the busywork and extra demands that complicate an already complicated life. In this system, I gain competence with the ancillary procedures but also have time to attend conferences, read up on patients and learn more medicine at the same time.

Bottom line: I think a university or community program with a VA system offers a great education. You may want a program where residents still spend the night on call - this gives you an opportunity to manage cases without consults and seniors breathing down your back (a lot of programs have switched to a night float system where you get a lot less overnight time).

Unfortunately, procedures in IM are rapidly drying up. Rather than fight this trend, we've simply changed the rules so that residents have to know about the procedures but not actually demonstrate proficiency in them. So, the fact that you didn't do much in med school likely isn't going to change too much in residency (with some program-specific exceptions).

That being said, most of the "autonomy" you get at the sort of places you mention is the autonomy to place patients in SNFs, arrange f/u appts, etc. As a resident at a busy tertiary center, you don't have to consult on every case. If you can handle it, handle it.

there are many programs which have multiple hospitals through which residents rotate including a university hospital, county hospital, and va. that way you can get experience in the different systems. three that come to mind that i interviewed at are university of washington, university of colorado, and university of alabama. i'm a resident at colorado so feel free to pm with questions.

that being said, you don't have to be at a county hospital to have lots of autonomy. i generally have had lots of autonomy in patient management decisions at our university hospital both as an intern and resident. residents run the show at night. as a resident, i also try to give my intern increasing amounts of autonomy, particularly as the year progresses. i listen to what their plan is for the patient, and if what they want to do is reasonable, we'll do it. early in the year, there are usually a couple of things the intern will miss, and it's my job to fill in the blanks. by the end of the year, a seasoned intern will generally have a complete and comprehensive plan for the patient. there is just one service at our university hospital where i feel like we have a bit less autonomy- our chf service. there the attendings tend to be more hands-on, specifying lasix doses or drip titrations.

at my program, i'd say residents have the most autonomy at denver health (county) and the va, next most at university, then rose (private), then the least autonomy at presbyterian-st luke's (private). while the level of autonomy is moderate at p/sl, there are benefits to rotating at a private hospital. you get to see how things are done in the real world. most of us will eventually go into private practice in the community. it just blows my mind how easy it is to get things done at p/sl. for example, if you want an echo there, you just write "echocardiogram" in the orders. no requsition form to fill out. and it happens and is read the same day. plus, the food is fantastic at p/sl, and it is generally a lighter month for us.

just say no to scut!

there is so much work to be done as a resident without adding on routine blood draws, iv's, or transporting patients. if you really want to get proficient at placing iv's, then do an anesthesia elective as a ms4 and put in iv's and art lines in pre-op.

if you are really into procedures, then ask about this during your interviews. find out if residents feel they are getting enough procedures. i just looked at my procedure log- i have done at least 12 art lines, 3 bone marrow biopsies, 12 central lines, 1 intubation, 5 LP's, 8 paracenteses, and 10 thoracenteses so far as a resident. i may have forgotten to log some. i have placed zero peripheral iv's. i watched one resident place an EJ (nurses on the floor don't do them). i feel like i have gotten plenty of procedures as a resident, and i am comfortable supervising interns for central lines, thoracenteses, paracenteses, LP's, and art lines.

you won't want to do all of this extra crap when you are a resident, I promise . . .

it's like a quarter to six pm on a non-call day, you still have two or three discharges to dictate, maybe two or three more to write for, you've got the floor paging you about an insulin drip, which is per protocol, but the staff cannot seem to figure out OR they are paging you to inform you, "they don't do insulin drips on their floor" and you will now need to write a transfer, on top of the transfer you were just headed to write . . . ect, Etc, ETC

You wouldn't have to have to deal with starting an IV in anyone when yu have that kind of crap to do, I promise. If you want to do stuff, just ask, and do it when you have time. You WIL BE MISERABLE if you go to a program where this is routine.

The answer to your problem/question is simple. Yes, there are high level huge medical centers with great opportunities for "scut work". Allow me to mention a few (mind you the great experience you get is from VAs and County, not the Uni):

Emory, UT Southwestern, UCLA, UCSF, UCLA-Harbor, NYU, Univ of Colorado, UW

The bottom line is, if you go to a place with only one hospital in its system and it happens to be a cush medical center for the rich and priveledged, you might get good academic and cerebral training but you'll suck as a doctor overall. I'm in my second month of internship and have already intubated and put in central lines at my program's VA ICU month. Go to Parkland in Dallas and you'll be doing everything.

The above poster is right though, I can see how doing all this for the rest of your life is too much and you'll hate it but come on, we should all be able to do these basic procedures well enough to be useful, otherwise you'll just be a brainiac. Anyone disagreeing and must have anesthesia/RT to intubate, nurses to put in an IV, IR to put in an LP/paracentesis, or a Site Rite ultrasound to put in a central line should be ashamed.

Note - some of the best programs (no names here) won't even allow people to intubate in the ICU unless it's anesthesia, or pulm/critical care fellow. To that I say forget it.

The answer to your problem/question is simple. Yes, there are high level huge medical centers with great opportunities for "scut work". Allow me to mention a few (mind you the great experience you get is from VAs and County, not the Uni):

Emory, UT Southwestern, UCLA, UCSF, UCLA-Harbor, NYU, Univ of Colorado, UW

The bottom line is, if you go to a place with only one hospital in its system and it happens to be a cush medical center for the rich and priveledged, you might get good academic and cerebral training but you'll suck as a doctor overall. I'm in my second month of internship and have already intubated and put in central lines at my program's VA ICU month. Go to Parkland in Dallas and you'll be doing everything.

The above poster is right though, I can see how doing all this for the rest of your life is too much and you'll hate it but come on, we should all be able to do these basic procedures well enough to be useful, otherwise you'll just be a brainiac. Anyone disagreeing and must have anesthesia/RT to intubate, nurses to put in an IV, IR to put in an LP/paracentesis, or a Site Rite ultrasound to put in a central line should be ashamed.

Note - some of the best programs (no names here) won't even allow people to intubate in the ICU unless it's anesthesia, or pulm/critical care fellow. To that I say forget it.

central lines and intubations are the the purview of the physician, same with spinal taps, etc. If your program will not you exposure to these physician related procedures then pass.

You don't want to be putting in IVs and drawing labs.

I'm already scouting out Pulm/CC programs and I'm not considering anywhere that will not allow the fellows complete control of airway management - EVEN IF it means I can't get the intubation, have to toss in a LMA and then need to page anesthesia, at least it will be my first try and my call.

The internist should come out of residency being comfortable doing all of these physician related procedures.

You don't want to be putting in IVs and drawing labs.
it actually sounds like the op does want to. i certainly don't. although i did take a phlebotomy course at the local community college when i was an undergrad. but honestly, it doesn't take an md to draw blood.

it actually sounds like the op does want to. i certainly don't. although i did take a phlebotomy course at the local community college when i was an undergrad. but honestly, it doesn't take an md to draw blood.

I heard the OP loud and clear. I'm just telling him he DOES NOT WANT!

http://www.threadbombing.com/data/media/44/do-not-want-dog.jpg

If you want to learn scut, just do an elective rotation or two at the end of your 4th year at a VA or county hospital.

You're in med school to become a physician, not a scut monkey. I agree you should aim to become proficient in these procedures but to choose your residency based on procedure volume is a decision you'll regret.

Hello all: I've been a long-time reader of SDN, and I thought I'd get some input on this dilemma. I'm a 4th year, somewhat disillusioned student at one of those 'big-name' programs in the Northeast. Consequently, I've spent the last year, and will spend this final year doing my required and elective rotations at huge academic medical centers.

I've learned a ton. I've done nothing. No blood draws. 1 IV. 2 ABGs. 5 NG tubes. 1 LP. I watched dozens of deliveries and caught the placenta for 5 (yeah I know, I'm going into IM so this doesn't really matter...). I'm not procedure-averse and I don't like being spoiled by a dedicated phlebotomy/IV/procedure/whatever team. I sincerely want to be proficient at these things. Am I ever going to be as good as the individual whose job it is to place IVs? Certainly not. Do I want to know how to put one in, even if it's a 'hard-stick', if that individual isn't around? Definitely. In fact, someday I'd like to spend a non-trivial fraction of my career working internationally, and then I won't have an IV team to page.

Sure, some might say that I'm just a medical student, and that I'll learn all these things during residency. But that is not necessarily what I've seen at these huge academic hospitals. And it's not just procedures, but also patient management. It's deciding what anti-hypertensive to give on the floor. Or how to work up this pancreatitis. Or whatever. Believe me, I love consulting the experts. I've done months on a consult service and it's fun. But for my residency, perhaps I want more autonomy. So here is where my dilemma arises.

Do I aim for a large urban county hospital, say for example USC LAC, Cook County, NYU Bellevue, Jackson Memorial Miami, where the patient volume is enormous, and ancillary services are less easily available, because I will get autonomy as a resident and learn by doing (which is what I prefer), while of course perhaps 'sacrificing' the 'best' (though that's questionable) didactics, research and fellowship opportunities, and venerable ranking?

Or do I stick with a big academic hospital, well ranked, good fellowship matching potential, 'good' didactics, and perhaps sacrifice autonomy?

Is it possible to have both?

I'm not posting this to compare the merits of specific hospitals and programs. I simply want to know what is a good training environment for an IM resident who learns by doing, but also isn't limiting for opportunities later. I've been to my share of teaching conferences and didactics. Morning report, senior report, noon conference, afternoon conference, junior report, attending report, attending conference, sign out conference, teaching seminar, physical sign rounds, and dozens more. Part of me loves that stuff. But another part of me says, you know what, I'll take a little hit on the didactic teaching end of things if I actually get to manage my own patients without having to consult on everything or needing a senior resident backup lurking in the call room during my call nights.

What do you think? I appreciate any thoughts.
I totally understand where you are coming from. I understand that phlebotomy etc. is considered scut work, but it’s important that you’re competent in certain procedures—in case you’re the only one in the room that can do it.

I’m also a MS4, and interested in IM and combined IM residencies. Up to the end of MS3, I’d only dropped two NG tubes, done two intubations, and drawn blood once during clerkships. That’s it. One strategy I took was to do an elective in anesthesiology, and I begged the nurses to let me do all the i.v. cannula placements. While it was painful at the start (for student and patient, I'm sure), I’m glad I did it because I’ve seen so much variation in this simple procedure that most students never do unless they look for it. Also, I just finished a IM rotation in the United Kingdom. While U.S. students have an edge in H & P’s and patient management by the time we graduate, the British students are extremely competent in the basic procedures you mention at the end of medicine school.

During my rotation in the U.K, we were expected to do a full H and P on every patient coming through the ED (not so new for us but new for local students), we were also expected to do the 12 lead EKG then read it, insert the i.v. cannula, do all the blood draws, and do the ABG if needed (new for me, not new for local students), then walk the samples to the lab. We were also called by the nurses to draw blood and to resite venflons if they could not do it. It was great experience and I’d happily do these procedures now.

I’m not saying that you need to go overseas before residency, but you see how creative you can be if you want this experience stateside as a medical student. Interestingly, when I told the British interns that we almost never do iv.’s, blood draws or ABG’s in the U.S. as interns in IM, they said that sounds like heaven to them and they say they would rather have more time to see more patients. It’s tough to know which system is better. My own philosophy is that we should be able to do these procedures if asked......

(selective quoting) when I told the British interns that we almost never do iv.’s, blood draws or ABG’s in the U.S. as interns in IM
I don't think this is the case everywhere in the U.S. I'm at a large academic tertiary program with a VA and a community hospital. This program should fall under one of the "big names" that the OP mentioned.

Tertiary hospital:
IV - nurses
Blood draws - phlebotomy team
ABGs - RT
MD for urgent or emergent phlebotomies and ABGs (which ABGs often fall under).

VA:
IV - nurses
Blood draws - phlebotomy team 3 times daily (except Saturdays, when phlebotomy team comes once). MD draw for all other situations.
ABGs - MD only

Our gen med time is split equally between the two sites; some residents spend time at the community hospital as well.

In addition, my program continues to require completion of the old ABIM procedure requirements prior to our graduation.

I'm a third year resident in IM at a large academic medical center. I have put in less than 10 IV's in my three years of residency. I've drawn blood maybe 20-30 times at most. I don't feel like I've missed out on anything. I've also done somewhere between 20-30 central lines, 20'ish arterial lines, 10-15 paracenteses, ~10 thoracenteses, ~ 5-10 LP's, more dobhoff/NG tubes than I'd ever care to place, and have gotten to drive a bronch. I personally feel that it is very important to acquire experience with procedures as much as possible. I don't really feel like IV's fall within that realm. I wouldn't worry too much about losing out on procedures by going to a large center.

To the OP:
Do NOT sign up to do residency at a county hospital. I know what you're going through, b/c I went to a similar med school and I was there with you (mentally/emotionally). The problem w/residencies at places like Cook County is there is so much scut it will exhaust you and also these types of hospitals tend to have malignant working environments. The scut you'll be doing is stuff like spending hours looking for nursing home placement for your patient...not the occasional blood draw that sounds cool to you now. Also, there just won't be as much time for teaching, which will be a bad thing for you. Again, I went to exactly your type of med school and I understand what you are going through, but don't make a rash decision that you will regret later.

There are plenty of large academic hospitals where you'll get to do some procedures. Pick any one that has VA rotations, or rotates through a large public hospital such as a county hospital. Or just ask residents when you interview whether they get to do many procedures.

I recommend an anesthesia and/or ER rotation for during 4th year, or even SICU or MICU. That way you'll get to do some procedures as a med student. You could also make friends with a nurse or phlebotomist and follow her around for part of a day, getting tips and instructions on putting in IV's and drawing blood.

Your life will be more complicated than you know as an intern. Don't make it worse by doing internship at a resource-poor hospital.