caps?

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I'm an R2 in neuro. My program, a large academic center, has neither individual call nor team caps. Call can be overwhelming. I recently admitted 11 patients in one 24 hr period. Just wondering if this is the exception or the rule.

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[CarefreeCFC]

My program covers 3 large hospitals, and we rotate between them (University, County Hosp, VA). None of the 3 services are able to "cap" formally. That said, when we do get THAT busy we often actively shunt appropriate admits to medicine services with us acting as consultants, simply to ensure patient safety.

It's an interesting position that Neuro is stuck in, though, and one that my fellow residents and I have talked about and kicked around lately. In the "real" world (ie, outside of academic & teaching centers), it's exceedingly rare for Neurologists to manage their own patients. We almost always act as consultants, which is usually to our benefit in terms of lifestyle. Exceptions would be Neurocritical care units, etc., but they usually have a couple of dedicated Neurointensivists managing them, as opposed to general Neurologists. During our training, though, we almost always manage our own patients. Also, most inpatient Neuro services have the same team admitting *every day*. It's not like Medicine where the manpower exists to rotate call q4, and give the off-call services a break and a chance to discharge patients. Add to that the fact that the inpatient Neuro team is often the same team taking Consults from other services and it can quickly become overwhelming at a good sized hospital...

I just finished a senioring month at our University hospital, and there was a point when it got so busy that I had to say to the staff "I think we've got too many patients to safely take care of.", and although we're not technically allowed to cap, we 'encouraged' the ED to shunt appropriate patients to other services. Bottom line I guess is that hopefully your staff is on your side and your patients' side, and if things are out of control he/she can put some staff-level weight behind supporting you...

 

[danielmd06]

I am a PGY-2 at a large program. We do not cap and yes, the calls become overwhelming...particularly on weekends.

I've admitted 14 patients in one 30 hr period, and the record at our institution is 17. Average weeknight seems to be 7-9 hits, and the weekends average 8-10.

We also get a fair number of hemorrhages and acute CVA's that receive tPA, so there is extensive ICU work to be done in addition to "routine" admits, direct transfers, and multiple consults.

I don't think that this has been a problem for alot of Neuro programs in the past. They didn't admit ICH's, and they often admitted CVA's to medicine services with Neurology consults. Now, Neurologists are attempting to take a more aggressive stance in hospitals.

In addition to increased workloads, I think it is not uncommon to find some Neurology attendings who are inexperienced with managing critical care patients and those with multiple medical problems - exacerbating the handicap.

Also, as you point out, it is not unusual for programs to have a "Stroke" team and a "General" team...each of which admits and sees consults on a *daily* basis. This results in no respite for the Neuro residents manning the front line.

The net result is acutally a threat to patient safety...as you suggest.

Our program has compensated by becoming much more aggressive in the patients we will NOT admit. We have asked our ER for help with this.

 

[minstral]

Are any of you willing to say where you are working? If not here please private messege me.

 

[CarefreeCFC]

Danielmd--
Really good points there in your previous post. The overall 'acuity' of Neurology has gone through the roof at a lot of training programs. One of the residency's grads (now in his 40's) likes to joke that when he got paged at night about a stroke, he told the nurses to get PT/OT/PMR involved and that he'd see them in the morning... Clearly not an option anymore.

We have a robust Interventional Neuro group and 2 Neuro ICU's between our 3 hospitals, and it's upped the urgency level at our program hugely in the past 3 years or so. As you said, we never used to take ICH's either, but now we're primary for them. For ischemic strokes IV tPA is always considered, but it's funny because now with the IN's around, it almost seems primitive. Now the priority is to get CTA/P within 30 mins of arrival and then off to the Angio suite ASAP for IA-tPA or MERCI for clot removal.

All these changes so quickly have resulted in some bewildered residents in my program. I've really got no interest personally in vascular neuro, so it's hard to watch the field and our program headed so hard in that direction. The non-stroke Attendings are really caught in the middle, and seem unable to keep up with the evolving standards in managing these patients. I always get the impression that they're really relieved to scurry back to their research labs when a new attending comes on...

In response, our residents and staff have gotten really heavy-handed both with the ED and other services about the type of patients we accept, simply out of necessity. I will personally be REALLY glad to graduate residency, do a nice cushy year of fellowship, and then get into private practice where the Neurologists aren't on the front lines of this interventional movement. In the real world, you either hire an IN, Neuro ICU staff, or Stroke specialists to do this stuff for you (and maybe a Nurse Practitioner or two), or else you don't offer those services at your hospital(s). Seems simple enough.

 

[danielmd06]

I'm at a program that is actually considered to be quite good. If you happen to interview with us, then rest assured you will be given a completely honest view of workload by both junior and senior residents.

I specifically chose my locale because I was heavily interested in Interventional, Vascular, Neurocritical care, and Neuroimaging/Neuroradiology as a medical student. I am still interested in those aspects of my specialty now, though I have lately become much more interested in other subspecialties such as Neurophysiology and Sleep as my residency has progressed (much to my surprise!).

I think it is a good thing that Neurology is growing. I also think that many of the aforementioned problems are part of the pangs of taking an increasingly prominent stance in the hospital hierarchy. It's hard on some residents now because the algorithms and templates previously used to structure Neurology residency programs are becoming dated in this era of increasingly acute, and specialized neurological care.

As more Interventional, Vascular, and Critical Care Neurologists percolate through the academic system, this problem will diminish.