Advice for new Interns, 2010

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Originally Posted by FaytlND

1000x this. If night float comes on at 6, and you get a consult at 5:45p, that's you're consult. It doesn't matter what a chief, attending or whomever says. And yes, if you sign it out, you are weak. Exceptions made for those occassions where you get 5 admissions/consults in the last half hour.

Disagree with that as a blanket statement, especially in a night float model, where it is shift work. If you're on vascular, and a vascular consult comes in, and you're going to be the one seeing it in the morning, then yes, it makes sense to just see it yourself. On the flip side, if you won't be seeing this patient again, then the night float guy can see it, and when he gets a 5:45am consult, you can return the favor.

I definitely try to "tuck things in" before I sign out, but I disagree that signing something out is weak. If you're pawning off your work on other people, that's weak, but giving a 5:45 consult to night float isn't weak if you're willing to return the favor.

I will say that perhaps the single most important thing to document is pulse exams on those vascular patient postop checks. It's happened at least 4-5 times where the team found the graft was down in the morning, but I had documented that I saw the patient and the exam was normal overnight.

Definitely agree there.

Originally Posted by TheProwler

Disagree with that as a blanket statement, especially in a night float model, where it is shift work. If you're on vascular, and a vascular consult comes in, and you're going to be the one seeing it in the morning, then yes, it makes sense to just see it yourself. On the flip side, if you won't be seeing this patient again, then the night float guy can see it, and when he gets a 5:45am consult, you can return the favor.

I definitely try to "tuck things in" before I sign out, but I disagree that signing something out is weak. If you're pawning off your work on other people, that's weak, but giving a 5:45 consult to night float isn't weak if you're willing to return the favor.


Definitely agree there.

Agree with all of the above, especially in an environment where work hours are being scrutinized. Additionally, with the 545pm consult, I think it is "weak" to sign out the busywork like late postops, family convos, following up on pm labs and culture. Given a decision between getting those things done and seeing the new consult, the night float guy would rather work up a new patient than clean up the grist from the daytime consults and surgeries. Our night float holds the pager until after conference but if they get a non emergent consult 630-8, the day team takes care if it. The take home point is nom that in everyone works together, no one truly gets "dumped" on.

Originally Posted by TheProwler

Disagree with that as a blanket statement, especially in a night float model, where it is shift work.

See, but this is the problem. On paper it's supposed to be shift work, but I just don't think it's the proper model for surgical education. Namely because if surgical residents get in the habit of approaching things as shift work, many of us would have a rude awakening once we hit our chief years and then in practice.

And you hit on one of the practical reasons why it makes sense to see the consult yourself--because in many cases you're going to be the one rounding on the patient everyday. I'd rather spend the extra half hour at night getting to know the patient than having to try and get a handle on it in the morning when I have a million other things to do.

As to the idea of being willing to see the early AM consults in return, I do agree that if you're going to sign out you're 5:45 consult you should be willing to see the 5:45am ones in return. The issue being that, again, it's much less stressful as the day person to stay late and see an evening consult than it is to try and figure out that early morning consult in the midst of all the regular morning work.

Finally, it becomes a slippery slope. If you're going to start saying "Well, we can just sign out that 5:45p consult", what about the 5:30...or the 5:00pm if you were in the OR until 6:00? It's actually more fair, and leaves less room for shenanigans from the less enthusiastic residents if you simply set the rules as "All consults from 6am to 6pm". Yeah, we're all in it together, and we should all be a team...but the reality is that it's not always the case.

Originally Posted by FaytlND

And you hit on one of the practical reasons why it makes sense to see the consult yourself--because in many cases you're going to be the one rounding on the patient everyday. I'd rather spend the extra half hour at night getting to know the patient than having to try and get a handle on it in the morning when I have a million other things to do.

I'm almost certainly not going to hand off a half hour consult, especially since finishing up 15 minutes after you're "done" is not a problem. I'm not usually out of the hospital less than 30 minutes after the on-call team taking over (we don't have night float). We certainly agree that seeing the patients that will stay on your team is beneficial, but at my program, the way the consult pager gets passed around means that you might see a consult during the day time but not be following that patient the next day.

I'm sure it varies from place to place, and depending on who is covering what, as well as what kind of consult it is. A vascular consult that needs a CTA or duplex tonight, so that we can then decide if they're going to the OR for the next 4-5 hours after that? At a program like mine, it would be silly to start seeing that when the night crew is clearly going to be doing the case.

Finally, it becomes a slippery slope. If you're going to start saying "Well, we can just sign out that 5:45p consult", what about the 5:30...or the 5:00pm if you were in the OR until 6:00? It's actually more fair, and leaves less room for shenanigans from the less enthusiastic residents if you simply set the rules as "All consults from 6am to 6pm". Yeah, we're all in it together, and we should all be a team...but the reality is that it's not always the case.

I think it's just important that people try to work together, and if someone isn't pulling their weight, one of their peers or seniors can tell them so. I work with people who will just tell me what they're thinking, so if I were dumping my work on them, they wouldn't take it.

Originally Posted by TheProwler

I think it's just important that people try to work together, and if someone isn't pulling their weight, one of their peers or seniors can tell them so. I work with people who will just tell me what they're thinking, so if I were dumping my work on them, they wouldn't take it.

This is key - both in residency and practice: knowing the expectations and communicating well. I have had experience where it was considered weak to sign out anything or to not see a consult, even if it was 559 am/pm and others where it was not a problem. Everyone needs to feel like they are treated fairly.

Originally Posted by Winged Scapula

This is key - both in residency and practice: knowing the expectations and communicating well. I have had experience where it was considered weak to sign out anything or to not see a consult, even if it was 559 am/pm and others where it was not a problem. Everyone needs to feel like they are treated fairly.

Yeah, I think similar to the documentation thing, there is going to be some institutional variance here.

We are very big on not having a "shift work" mentality..I've stayed late a ton of times to take a patient to the OR or follow up on something critical. That said, the guy taking the consult calls after 6pm is one of my PGY2 or PGY3 peers - so sometimes he'll take a bullet for me and I'll take one for him if it means getting out of the hospital a little bit sooner.

The one issue about the 5:45 consult is that in my program, it wasn't a 30 minute issue. By the time you saw the consult, staffed it with the person who was available or not, did the note/orders, communicated the plan, etc it was often over an hour or more of work. And often times, night float was sitting around doing nothing. In my program, our attitude tended to be one of "hey, if I'm here, I want to do as much work as possible so other people don't have to be."

In private practice now, depending on the situation, we will often hand off consults to one another that come in the 6-7 AM hour. For instance, the other surgeon in town saw a patient at 6:15 this morning who may or may not have needed an operation. After 6 days on call, he was headed up to a small town an hour away from us to do outreach. I was more than happy to take over the care of that patient, and anticipate that he would do the same for me in a similar situation.

I think the 5:45 consult is not really the issue. I think it's usually the right thing for the night guy to take it and get the day people out of there, but it also depends on what else is going on in the service. This situation just needs a conversation between day and night. Usually something like-- Day: There is a consult that just came in, I will see it before I leave. Night: No you go home, I'll take care of it, I'm here all night. Day: Thanks, I'll get you back. --Everybody's gotta play nice, because we'll all be in that situation at some point.

I think where you get into problems and what is more inappropriate is signing out obvious day work--ie. postop checks from morning cases, preops for the OR the next day, calling consults, following up notes, PM rounding, orders, dressing changes.

Originally Posted by cpants

I think where you get into problems and what is more inappropriate is signing out obvious day work--ie. postop checks from morning cases, preops for the OR the next day, calling consults, following up notes, PM rounding, orders, dressing changes.

Bingo. Don't ever sign that stuff out...

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