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Malignant IM Residency Programs

Discussion in 'Internal Medicine and IM Subspecialties' started by futuredoctor10, Aug 21, 2013.

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  1. futuredoctor10

    futuredoctor10

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    I keep hearing about "malignant" residency programs. My two questions:

    1) What schools are considered to be malignant for IM?

    2) What exactly do people mean by this term? My understanding is it applies to programs who do not abide by duty hour restrictions, overwork the residents, or have little to no elective or ED time (all ICU/wards intern year).

    Some schools I have heard that are "malignant" include Mass General, Duke, UMichigan, UT Houston, and UAB. Would be interested in residents from these programs to comment whether they feel this is true, why/why not?
  2. Deferoxamine

    Deferoxamine Non-smoking

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    :corny:
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  3. Kal EI

    Kal EI

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    .
    Last edited: Aug 25, 2013
  4. Instatewaiter

    Instatewaiter But...There's a troponin

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    Schools aren't malignant... programs are.

    Malignant is a nebulous term. Some people use it to mean you work hard. Many programs are going to go over work hours. It is just how it is and you should probably accept that you will break work hours a few times during residency.

    You chose a few strange programs to list as malignant. I think you are talking to ******* who probably whine about BS if they are saying those programs are malignant.
  5. futuredoctor10

    futuredoctor10

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    Yes I completely know and accept that work hour restrictions are broken. I know I will have to work hard in residency. My only concern was what exactly this term meant and if there are any red flags to be aware of.

    Which is why I thought hearing from residents at these schools directly may be able to more accurately comment and explain why the perception exists and if they feel it is true or not.
  6. Instatewaiter

    Instatewaiter But...There's a troponin

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    Malignant means the residents are belittled, overworked and/or unappreciated with poor opportunities for education. They tend to be residencies about service rather than education
  7. IMPD

    IMPD

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    This is a good definition. There is no official list of these programs as they vary from year to year and the complex interaction of hospital needs and program politics. There are some places that have that history and probably skate closer to the duty hours edge than others. People will self-select to those programs because once you go and interview, it will usually be clear.

    Students have this great fear that they'll be "tricked" or "misled" into choosing a program that "turns out to be malignant". This is almost never true. You could be at the greatest cush program in the world, but if you have an epically sh*tty intern year, you will view your program as malignant.

    Programs can no more "hide" their nature and style than someone can hide on a day-long first date. If you are dazzled by their car and never pay attention to their constant stream of abusive language towards you, then yes, I guess you could be fooled.

    The key here is talk to residents and try to evaluate programs based on what they say and what you see when you interview. Everything else is rationalization and bullsh*t. Programs who emphasize "how hard you work" and "being tough" and don't show you sample schedules with days off are going to work you. No surprise. Programs where residents say "well, yes, we work really hard, but it's worth it", are going to work you.

    Believe what programs say. Believe what residents say. Don't believe your "idea" of the program. If you leave a program interview day with an unsettled feeling, believe that feeling. You may still choose to go there, because, hey, you're tough and it's worth it, but understand what you're getting into.
  8. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I don't get the reason for why 80 hour work weeks are necessary, why not set the cap at something more reasonable like 40 hour workweeks? I think I'd be pretty pissed off if I found out the intern/resident taking care of me has been at work for the last 12 hours instead of fresh.
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  9. Silent Cool

    Silent Cool Member

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    You're not alone in that opinion. You probably wouldn't hire anyone for anything if they were on their 80th hour that week.
  10. rokshana

    rokshana Member

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    interestingly enough though...decreasing the number of hours worked didn't changed the number of errors made...frankly IMHO they are going to find MORE mistake with the even stricter hours of 16 hours for interns...why? the number of handoffs are crazy now...frankly I would not want the intern or resident who is taking care of me or my family member to be the last one in the game of telephone that is handoffs...better the tired resident that knows me than the fresh one that has no clue...
    Last edited: Mar 10, 2014
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  11. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I mean, maybe a better way might be to keep the long days (12-16 hours) but mandate that there be days off in between the long days. Work 14 hours on Monday, you're off Tuesday, etc.
  12. KnuxNole

    KnuxNole Sweets Addict

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    Prepare to be pissed off if you get admitted to a hospital :eek:

    40 hour workweeks would require a prolonged residency program. Especially in certain fields. Surgery residencies might take 8-10 years..

    And Sparda, there are mandates for days off. Also, if someone works a 24 hour shift(or 30), they get the next day off as post call. Interns don't get that luxury. For the record, working 80 hours in certain services is far from a program being malignant :p

    40 hour workweeks sound good, but as a physician(especially as a resident), it seems unheard of. There is a difference between being abused by work hours, and being coddled and not being well trained...which is the main priority of residency by far.
    Last edited: Aug 24, 2013
  13. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    Damn, lol. I guess I'll ask my IM private practice doc which hospital he works out of and just go there if I get sick.
  14. KnuxNole

    KnuxNole Sweets Addict

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    Haha, don't assume someone who is up at the 12th hour = a poor clinician. Most people can survive no problem and think rationally on the job. Those who have trouble will learn. That is one positive thing about having 3rd year rotations which don't baby you. And having an intern year that makes you work hard(while not abusing you), so that you won't be a weak physician. Trust me, if you go to the ED at 7:00pm and need to be admitted, the resident who is there since 7:00am will do just fine taking care of you!

    Regardless, ACGME mandates an 8hr rest periods between work days. Sure, it's not always practical to go home and sleep immediately, but I think it's not as scary as it sounds. 12 hours is definitely not toooo long :p
  15. firewall62

    firewall62

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    In principle, yes, but it's not unusual for post-call residents to stay until the afternoon on their post-call "day off."
  16. rokshana

    rokshana Member

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    don't be surprised if he says that he doesn' t admit patients to the hospital...
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  17. Instatewaiter

    Instatewaiter But...There's a troponin

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    I lol'ed at this. Perhaps I can also get sensual massages from a unicorn while Santa Claus reads me bedtime stories if I ever happen to go over 40 hours.

    ****, many programs have trouble keeping people below 80 hours. The sheer number of extra docs you would need would make this untennable.
  18. Kal EI

    Kal EI

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    Which is why midlevels are moving in to all fields in medicine.
  19. Mis

    Mis

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    Malignant Residency Program Southampton Hospital NY, Internal Medicine, Transitional Year, and Surgery.
    Never go there .
  20. rokshana

    rokshana Member

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    10 to 1, he doesn't work out of any hospital…probably doesn't admit to the hospital…or has a hospitalist group that handles his pt when they are admitted…and if you think the hours and census are crazy for a resident…they are NO caps or hour restrictions once you are an attending...
  21. notinkansas

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    The term "Resident" comes from back in the day when training was much more like indentured servitude or being in the army. Trainees were called "Residents" because they literally lived in the hospital. They were on call 24/7. However, patient acuity was much, much lower. It used to be that someone would get admitted to the hospital the day before a hernia operation, for example, and then stay for a week. The model for training was basically that if you worked in the hospital as an apprentice for long enough, you'd pick up enough medicine to be a decent doctor.

    The 80 hours limit came about as the result of a lawsuit in NYC. The daughter of a journalist died after being seen in the ER. There was lots of complexity in that case, including her failure to be honest about what drugs she had taken. But, since it was a journalist's kid, the suit was filed and "the system" was blamed. When the public found out about power weekend (being on call from Friday night- Monday AM), like you, the were horrified. But data also shows that just as many errors result from handouts.

    Bottom line, medical training has never been a well thought out educational program. The whole system could use a thorough re-vamping, which will be very difficult due to various political interests.
  22. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    What do you expect, it's in the Hamptons.
  23. throw away

    throw away

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    The journalist/lawyer had a dark side. He hated doctors and called them "murders", even publishing long articles about how doctors purposely killed his daughter and treat people like "dogs". That said, every time I have a day off, I think about how much I LOVE that guy!
  24. rokshana

    rokshana Member

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    actually it was a lawyer's daughter…lots of fuss about tired interns and residents…not so much when it was discovered she wasn't forthcoming about the meds she was on….
  25. DermViser

    DermViser

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    Yes, bc as a PharmD you would know about malignant physician residency programs.
  26. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    Don't need to be a doc to know that the Hamptons are ****ty.
  27. DermViser

    DermViser

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    Yes, bc I'm sure Harlem is much better.
  28. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    Definitely is. Not many places where you'll see more cases.
  29. DermViser

    DermViser

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    Yeah, um medical residents these days aren't just looking for "more cases", esp. in Internal Medicine. The "type" of patient you have to deal with it is important to some people as well.
  30. Otto of the Silver-Hand

    Otto of the Silver-Hand Account on Hold

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    My dad used to tell me war stories about those days. Interns used to wear all white uniforms, slept inside the hospital, ate at the hospital cafeteria, weren't allowed to get married and weren't paid. Residents were able to dress as civilians, were allowed to get married, had housing on the hospital grounds, and were given meal and laundry money.

    I was an intern in NYC at the start of the Bell Commission ( though none of the hospitals followed it). Libby Zion was the daughter of Sidney Zion a lawyer and columnist for the NYT . She came to the New York Hospital delirious. The intern ( who later became an oncologist) and the second year resident ( who later became a cardiologist) treated her with haldol. Zion's attorneys argued that the delirium was secondary to sepsis and that she should have been given antibiotics. What was notable about this case was that Zion not only sued the Attending ( who I believed later settled) but also sued the intern and resident (this never happened before). Because of this, the supervision and hours of the house-staff came under criticism. (The Bell Commission was formed and made recommendations about the amount of hours house-staff should work. So after Libby Zion, almost every residency in NYC had an every fourth call with night float. Overnight calls only happened on Fridays and Saturdays.) The Case ended a couple years ago and the former intern and resident had to pay $1 each.
    It' s only since ~ 2008-2009, that NYC hospitals have been strictly enforcing the 80 hr work week. Some hospitals won't allow moonlighting because that counts against the 80 hours and some places even split the ICU teams into days and nights.
    However, the Libby Zion Case had further ramifications in malpractice law in NYC. Ever since Libby Zion, the malpractice lawyers have been suing house-staff. Damages awarded are based on the future earnings of these residents.

    Back to the OPs question, the most malignant residencies are in NYC ( no matter how prestigious the hospital). Just my $.02.
    Last edited: Mar 13, 2014
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  31. Otto of the Silver-Hand

    Otto of the Silver-Hand Account on Hold

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    CPMC is in Spanish Harlem (aka Washington Heights). Ever since Bill Clinton moved his office there, Harlem is gentrifying and is becoming a desirable living locale. A Harlem brownstone costs millions. The South Bronx ,though, is another story....
    Last edited: Mar 13, 2014
  32. Mistuda

    Mistuda

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    The Osteopathic IM Residencies in Southern Florida (just IMO)
  33. keindo

    keindo

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    A lot of research in this area is really ****ty and dependent on how one defines errors. In my "top 10" institution (one of 20!) some of the faculty that were doing research into this were super biased.

    I think the fact that most of the research shows that errors didn't decrease actually supports hour caps.
    1. Hour caps are relatively new systems and you would expect an error increase with a new system.
    2. If two products are the same, shouldn't the default choice be the more humane option (e.g. not working people 80 hours a week)?
    3. Residents get very little training or education in how to conduct a good handoff (at least in places I've been to). It seems we could improve how handoffs are done, which would reduce errors. On the other hand, it is probably not possible to improve how residents function on their 80th hour.
  34. IMPD

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    Errors are important, and what my faculty complain about is not errors, but ownership.

    If it were possible to create a sense of immediate ownership. To forever banish the phrase "I'm just covering", then the work hour rules wouldn't be so hated. As it is, it is not just residents who have adopted the "I'm just covering". I don't know what can be done to help ownership...I do know that seeing the patient through the first, often rocky, 24 hours, helped create it. Is there another way? If anyone can figure out how to do that....
  35. darkelven29

    darkelven29

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    I think sometimes it's hard to predict what might happen in the evening shift vs. during the day and sometimes the day team didn't pass along information that they thought would be important/happen. Families usually come after work hours, and it's hard to explain things that happened during the day if you are night shift and wasn't present during rounds. So you say "I'm covering," especially you get handoff on the important things and overall picture, not all the little details and reasoning behind certain workup.
  36. notinkansas

    notinkansas

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    This is one of the WORST parts of cross covering- dealing with the angry families. They come in and and claim that nobody has talked to them at all and DEMAND to talk to the doctor RIGHT NOW. Then the poor schlub cross covering, who already has plenty of "real" work to do has to go diffuse a situation he or she shouldn't need to be getting involved with at all. Of course families get even more upset to learn that the main doctor treating their family member isn't available to them on demand 24/7, but then on the other hand, the public gets horrified at the idea of 8o hour work weeks. You can't have it both ways, folks...
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  37. dozitgetchahi

    dozitgetchahi

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    It wasn't Haldol, it was Demerol...and the chick was taking an MAOI. Cause of death: serotonin syndrome.

    Read the many well-researched articles on the internet about this if you don't believe me. This was one of the cases that (thankfully) led to the loss in popularity of Demerol as an analgesic.
  38. dozitgetchahi

    dozitgetchahi

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    Oh god yes...I absolutely ******* hate dealing with these types of calls. They usually become a total ****show where the family demands that someone come down and 'go over the whole treatment plan' with them - yeah right, like I'm really going to be able to do that for some patient I've heard a 30 second blurb about at signout - and then they get furious when you're not able to put them in contact with their patient's intern. After several extremely time-consuming episodes with irate families that could not be satisfied no matter how much effort I put into trying to help them, I now tell the nurses that it's inappropriate for me to get involved with going through treatment plans on patients I barely know and the family needs to speak with the primary team during normal working hours the next day.
  39. Deferoxamine

    Deferoxamine Non-smoking

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    Yes, and most of the irate family members are usually the estranged daughter/son from 2 time zones away who feel guilty they didn't stay in touch with Daddy for the past 30 years, and now his LVEF is crapping out and HOW DARE THE INTERN NOT UPDATE THEM WHEN THEY SHOW UP AT 7:30PM WITH A STARBUCKS AND AN ONGOING CONVERSATION ON THEIR BLUETOOTH EARPIECE.
  40. Raryn

    Raryn Infernal Internist

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    She was given haldol too, which can potentiate serotonin syndrome.

    Not to mention the cocaine that she was taking. Lots of well-researched internet articles about that one too.
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  41. Psai

    Psai aw little buddy

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    I'm not understanding how they won the case...
  42. flipmd

    flipmd

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    Because they love their family member so much that they are only available to talk to the doctor at 9pm. What I tell the nurse is to tell the patient that the night doctor is only there for emergencies, and to leave their contact number so that the primary team can call them in the morning. About half the time it's just the RN not wanting to talk to the family and passing the buck off to the MD.
  43. flipmd

    flipmd

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    In medical malpractice, it doesn't make sense a lot of the time.

    I think it had to do with not getting a good history about her using MAOI, and giving her more and more Haldol / Demerol as she got more confused and confused, febrile, etc. They didn't catch the serotonin syndrome they were giving her.
  44. Otto of the Silver-Hand

    Otto of the Silver-Hand Account on Hold

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    NYC is also very plaintiff friendly in malpractice cases.

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