Things I Hate About Third Year

[ProfMD]

Really? At most places you can just send the patient down to radiology and we can advance it under fluoro. Done deal.

As for consulting surgeons for a central line? That is rare too. Radiology can usually get it done faster as well.

A lions share of procedures which are classically done by specialists are done by radiologists (non-interventional) these days. Image guided biopses, LP's, dobhoffs, G-tubes, central lines. And why not? Radiologists can get it done quickly, efficiently, and safely with image guidance. Best of all, our standard answer to your consult is "yes".

I agree that fluoro is overkill for dobhoffs. Our nurses routinely place them at the bedside, including transpyloric, and then the docs just get and x-ray for confirmation.

Also, at least where I am at, PICCs are now being done more at the bedside and less by IR.

And also, the standard answer of yes part is highly institution dependent (as it is for responses to any consult request). I have worked places where radiology would do the procedure, but not at night or on a weekend, and as long as they were not busy with other stuff.

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[DeucesHigh3]

I agree that fluoro is overkill for dobhoffs. Our nurses routinely place them at the bedside, including transpyloric, and then the docs just get and x-ray for confirmation.

Also, at least where I am at, PICCs are now being done more at the bedside and less by IR.

And also, the standard answer of yes part is highly institution dependent (as it is for responses to any consult request). I have worked places where radiology would do the procedure, but not at night or on a weekend, and as long as they were not busy with other stuff.

More evidence that all of this is very much institution-dependent. It's very idiosyncratic as to which procedures are considered humdrum, and which ones are hands-off except for specialists. At my internship hospital ("community", but with residencies in IM, surg, OB/Gyn, and family), the following is true:

-PICCs are 95% done at bedside by a nurse PICC team
-Dobhoffs are ABSOLUTELY never passed by RNs, and when the residents do them it isn't assumed that transpyloric is even a *possibility*. Also, they won't be touched except in IR under fluoro if there is even the faintest whiff of altered anatomy.
-All central lines done by Surgery. Yes, basically all of them. There are something like 5 medicine residents signed off on CVC placement, and even most of the pulm/CC attendings don't really like placing lines.

 

[badasshairday]

I think it happened more towards the beginning of the year when people were getting their legs under them; they tapered off a bit further into the year. It's still shameful for any surgical service to call ENT for it though. And a huge waste of our time. I'm more than happy to let radiology take care of those "consults", but that doesn't really happen here. I think fluoro is absolute overkill anyhow for a NG/dobhoff. Unless a patient has real stenosis or altered anatomy it's usually because the team is just shoving it in and hoping for the best instead of positioning the patient properly.

I can't say I've seen radiology do G-tubes. Curious how that works.

NG, insufflate the stomach, fluoro, poke, place tube is how it works. Just make sure you don't hit transverse colon, that would be bad We typically do the ones that GI has problems doing endoscopic. Weird right?

And yes, placing an NJ doesn't require fluoro. Correction, we advance them to the small bowel only when it is needed if they are having problems.

 

[badasshairday]

And also, the standard answer of yes part is highly institution dependent (as it is for responses to any consult request). I have worked places where radiology would do the procedure, but not at night or on a weekend, and as long as they were not busy with other stuff.

True. It is a service offered at most places during day time hours for the referring physicians. Helps referring docs by freeing up there time to do other things (i.e. Hospitalist rather being doing new admit or finishing rounding than doing a thoracentesis) Procedures often covered by radiology groups include LP, thoracentesis, chest tubes, paracentesis, abdominal/pelvic drains, central lines/dialysis lines, ports, biopsies basically anywhere. While there is a procedure team in house it makes sense which is why it is usually a day time service.

 

[badasshairday]

Practice patterns... We control virtually all the endo that we want at our hospital. Nobody would have IR place a line. We would place it under flouro. Or, if in a pinch/I was bored, I have dragged an x-ray tech to the bedside with a machine and done the line with a flat plate. I am in no way saying that that is a good thing in and of itself. But, it does mean that IR stays out of the complex endo that we DO want. Something that is somewhat unique to us also, 30%+ of our vascular patients are ESRD. This is obviously way above normal for a typical tertiary care center and a reflection of how some of the practices were built. This means that our central occlusion/stenosis rate is way outside the bounds of what people will see normally. Also with the high number of ESRD patients, the number of patients that need a quinton per day is actually quite high. We have 40+ nephrologists that come to our hospital and none do quintons, so it falls to us.

I find the history of vascular surgery fascinating. A field that perpetually talked about the inferiority of IR procedures now has turned face over the past 10 years when they accepted finally that Endovascular intervention has lower morbidity, mortality, and pay better per unit time than those long, laborious surgeries. Only took 3 decades to change.

 

[VisionaryTics]

Well we (ENT) get consults to place dobhoffs, so not entirely surprising that vascular sometimes gets consulted for a line.

I think we've flipped out on the consulting teams enough that it's gone down dramatically, though.

Okay I'm really glad this isn't just my hospital.

The only services that do it routinely are MICU, CCU, and OB/GYN. But god dammit do I hate Dobhoff consults.

I remember I was once paged to REMOVE a Dobhoff on a patient who had recently had a nosebleed that I had packed. I was blind with rage. When I packed the nose, the patient was intubated. When I stormed into the room past the medicine resident, ripped out the Dobhoff, and stomped away, the patient was awake and talking. I did not realize this until he shouted "Thank you!" down the hallway after me.

 

[VisionaryTics]

Regarding students and learning about central lines. I agree that students should not get hung up on doing or not getting to do procedures. But, in the same way that learning how to take a good H&P is incredibly important, learning about IV and central IV access is important for anyone that is going to be in the inpatient setting. The number of inappropriate line placements is staggering, as is the complication rate (talking globally, not just at our hospital). At least once a month we get a referral from the community for a patient with a retained guidewire. Being exposed to and forced to think about WHY a line is being placed is good for medical students. Regardless of the specialty they are going into...

Totally agree

1. Placing a line is not rocket science, but is fetishized but medical students/interns because it's a "real procedure"
2. More important and more salient to medical students is learning about different types of IV access and indications for each

If our interns on ICU spent a quarter as much time learning about fluids as they did putting lines in patients, they wouldn't be ordering D5 1/2 NS at 83cc/hr for every patient on the service. Drives me insane.

 

[Psai]

Totally agree

1. Placing a line is not rocket science, but is fetishized but medical students/interns because it's a "real procedure"
2. More important and more salient to medical students is learning about different types of IV access and indications for each

If our interns on ICU spent a quarter as much time learning about fluids as they did putting lines in patients, they wouldn't be ordering D5 1/2 NS at 83cc/hr for every patient on the service. Drives me insane.

Uh bro do you have a few minutes to teach me how to put the line in tho

https://www.reddit.com/r/medicine/comments/3ynr6o/resources_for_the_list_of_most_bangforbuck_things/

Gonna go through this in a few days

 

[VisionaryTics]

Uh bro do you have a few minutes to teach me how to put the line in tho

https://www.reddit.com/r/medicine/comments/3ynr6o/resources_for_the_list_of_most_bangforbuck_things/

Gonna go through this in a few days

That's a pretty good list for general purpose intern.

I would definitely add wound management. Not suturing or anything, just knowing how to assess and dress wounds. Being able to look at a wound and see whether it's healing/not healing, early, chronic, granulating, breaking down, fistulizing, infected deep vs. superficially, nec fasc, etc is such a useful skill but rarely practiced because no one takes down dressings aside from nurses and surgeons.

 

[VisionaryTics]

Also managing wound breakdown/chronic wounds. Recognizing devitalized tissue, checking factors that affect wound healing (TSH, Alb, etc), supplementing diet appropriately, dressing wounds (just know how to put strip gauze or simple wet-to-dry).

 

[Wordead]

Okay I'm really glad this isn't just my hospital.

The only services that do it routinely are MICU, CCU, and OB/GYN. But god dammit do I hate Dobhoff consults.

I remember I was once paged to REMOVE a Dobhoff on a patient who had recently had a nosebleed that I had packed. I was blind with rage. When I packed the nose, the patient was intubated. When I stormed into the room past the medicine resident, ripped out the Dobhoff, and stomped away, the patient was awake and talking. I did not realize this until he shouted "Thank you!" down the hallway after me.

Usually with services like obgyn / ortho I can shame them into cancelling it by some rendition of "don't you consider yourselves surgeons, does your attending know you're calling this consult"

 

[cbrons]

Usually with services like obgyn / ortho I can shame them into cancelling it by some rendition of "don't you consider yourselves surgeons, does your attending know you're calling this consult"

Obgyn prob does not care

Sent from my SM-N910P using SDN mobile

 

[badasshairday]

....the actual steps of where to stick a needle and how to hold the ultrasound probe are something that we could probably teach a primate.

I'm just a knuckle dragging interventional radiologist.

 

[aDOdoctor]

I'm just a knuckle dragging interventional radiologist.

Docs like to think that because it's so simple it's not worth teaching and that students should just "know about it and why it's done," then tout on how much they did during their years of training and complain about the incompetence of residents (Dobhoff example above).


VisionaryTics, you're the problem. Not the resident. I guarantee you that if you taught how to remove the tube you would never get a call from him again. But I forgot, you're too good for that and act high and mighty because you got pulled from the physician's lounge while talking about the game last night.

 

[Señor S]

If something is so easy and basic then that's a perfect thing for a student to take a shot at it. "It's so easy that you don't need to learn it right now" is just another idiotic doctorspeak cliche.

 

[Raryn]

If something is so easy and basic then that's a perfect thing for a student to take a shot at it. "It's so easy that you don't need to learn it right now" is just another idiotic doctorspeak cliche.

It's not easy and basic, but it is just a technical skill. You need time and focused effort to get good at lines, and that's not something you're going to get during a single student rotation. We could teach a motivated HS student those technical skills... but would need to get them significant amounts of practice before they could do it on their own. No doctoral level thinking involved in the vast majority of the actual technical placements once you identify the appropriate patient and site for the line. (there are complicated lines that can require quite a bit of technical creativity... but that's something you learn via volume)

So for every student to just get one or two random lines does give them a taste of the procedure, sure, but it's not something that's going to make any real difference in the long run. Either you'll end up in a field/program where you'll do them regularly or you won't. On the other hand, the knowledge of indications/contraindications for different types of line placement? That will be important for everyone.

 

[aDOdoctor]

It's not easy and basic, but it is just a technical skill. You need time and focused effort to get good at lines, and that's not something you're going to get during a single student rotation. We could teach a motivated HS student those technical skills... but would need to get them significant amounts of practice before they could do it on their own. No doctoral level thinking involved in the vast majority of the actual technical placements once you identify the appropriate patient and site for the line. (there are complicated lines that can require quite a bit of technical creativity... but that's something you learn via volume)

So for every student to just get one or two random lines does give them a taste of the procedure, sure, but it's not something that's going to make any real difference in the long run. Either you'll end up in a field/program where you'll do them regularly or you won't. On the other hand, the knowledge of indications/contraindications for different types of line placement? That will be important for everyone.

You have to start somewhere. Usually the first one.

Also, I'd like to add that on my anesthesia portion of my surgery rotation, I got to do more than I ever did because the attendings allowed me to. Even though I fumbled intubating and placing IVs, I learned what to look for and how to troubleshoot myself, and what the process of inducing someone entails by being in the thick of it. I also had more of an interest to research and learn about it because I was involved in it. It was fun to me, despite not having any interest to be an anesthesiologist. It took literally zero effort from the attendings to do any of this, and if they saw I struggled, they'd jump in and tell what what I could do to get it right the next time. To me, that very small time period was one of the most fulfilling moments I had throughout the entire year.

That's why we pay for medical school, so we can do things that laymen aren't allowed to do. Any regular Joe can read about indications and contraindications. How does that differentiate us from anyone else?

 

[Señor S]

So for every student to just get one or two random lines does give them a taste of the procedure, sure, but it's not something that's going to make any real difference in the long run. Either you'll end up in a field/program where you'll do them regularly or you won't. On the other hand, the knowledge of indications/contraindications for different types of line placement? That will be important for everyone.

The basic knowledge can usually be learned better from books or the internet; it's not something that you need spend 12 hours/day in a hospital to acquire. Actually the time you spend (or at least the time I spent) watching people put in central lines/intubate/deliver babies/do surgery is probably a net negative because every minute is a minute less to spend on UWorld or UpToDate.

Third year for me has been a profound, almost criminal waste of time. I won't generalize my experience to everybody but I will say that a) people who criticize 3rd year are usually doing so for good reason and b) the social and economic climate will only continue to marginalize students.

 

[TheFutureFatMan]

The basic knowledge can usually be learned better from books or the internet; it's not something that you need spend 12 hours/day in a hospital to acquire. Actually the time you spend (or at least the time I spent) watching people put in central lines/intubate/deliver babies/do surgery was probably a net negative because every minute I spent doing it was a minute less to spend on UWorld or UpToDate.

Third year for me has been a profound, almost criminal waste of time. I won't generalize my experience to everybody but I will say that a) people who criticize 3rd year are usually doing so for good reason and b) the social and economic climate will only continue to marginalize students.

So what about fourth year?

Also...is there anything incoming students should know, in order to make sure we get the most we can out of 3rd? Thanks!

 

[Señor S]

So what about fourth year?

I'll get back to you on that.

Also...is there anything incoming students should know, in order to make sure we get the most we can out of 3rd? Thanks!

No general advice as everything is very school specific. For us it's usually the shelf that determines your grade so study as much as you can.