jimdoc said:
No way as a medicine intern you did over 100 central lines....(this is conservative estimate). Now I often get called into the MICU for tough central lines/ intubations/ pa catheters...even at a top 10 hospital with pulmonary fellows...these guys stumble still, and i have NEVER seen a medicine intern or chief put in a cordis.......perhaps those surgical residents were foreign grads they often make do a surgical residency, or perhaps there were at a ploace like where here where only the cardiac fellows place chest tubes....Only surgical residents or cardiology fellows were allowed to float a PA catheter, so in the middle of the might, i would have to go to the MICU as an INtern, while the medicine chief watched me because the card fellow was at home.
My surgical ICU months/cardiac months as an anes resident were very easy...except for the LVAD patients......
In the ORI, I often felt more competent than the younger anesthesia attendings placing a cordis my first month of anesthesia residency, certainly better than most of the CA-3 residents I had done more of them.....I have no problem dropping a subclavian if I can't get the IJ, as well as all of the trauma experience....
This is my experience only, but if you go to a good community program, you will have lots of PA's, efficiency is a must, these place are in the profit business....I only did discharge summaries on weekends. Yes, even whe there were no hour limitations, it was fun.....If you are assertive, you will operate a lot..I still feel like I could kick the PGY-4's ass on a lap chole here....They just don;'t do enough because we have laparoscopic fellows.......
my two cents, but who the F*#& wants to spend half the day rounding....absolute torture. with the 80 hour work week, and going home post call, there is no way I would do a medicine internship.......Like I said, my internship was actually kind of fun.....even at 110+ some weeks.
I think you hit on two key points that helped make your experience and my experience as rich as they were: It's all about your confidence and aggressiveness in pursuing procedures and the confidence the staff has in you. I still have those ridiculous procedure books we were given to log in procedures. The number of procedures you got was definitely site specific but also resident driven. Not over 100 central lines as an intern (78 to be exact) but more than the surgery guys in my program. At some of the sites I rotated at predominantly, the MICU intern also covered the SICU. Granted this was a long time ago and may have changed, but you also helped out in the ER. The floor residents absorbed much of the useless scut.
If there was a surgery resident in house, they would usually be willing to let you do the procedures, especially since you were covering the medical issues and calls of their patients in the ICU. You take too long and they would take over, but otherwise they were available to back you up. I even got to cric several patients during codes where the surgery resident wasn't available for either a trach or as backup for intubation (3 out of 4 did have reasons for a cric - angioedema, obstructing mass, refractory asthma exacerbation - one unfortunately was an iatrogenic injury to the patient's epiglottis and right VC from multiple failed intubation attempts). Those put a few grays on my head and got one surgery resident fired for leaving the hospital on in house call.
The cardiology service of St. Paul University Hospital was/is a very resident friendly service and was where you got to place introducers and float PAC's. Clyde Yancy, Brian Baldwin, and Beth Bittner all gave me those opportunities on the cardiology patients when the fellows were busy or if there were no fellows available. Also got my first exposure to TEE, though couldn't really drive the train so to speak. Lot of exposure to ECG reading, TTE, and management of complex cardiac dysfunction.
The nephrology service of Southwestern places all of its own dialysis access catheters and will probably start it's own interventional service at some point next year.
The pulmonary service does it's own chest tube placements and again, if you had read up and were eager to do them, you got them. Quite frequently, as you said, the pulmonary attendings looked very uncomfortable placing them, so if you had the confidence and previous experience on your surgical sub I's or rotations to at least see how the surgeons did it, you could place them faster than the attendings. If you didn't know squat, thought an alcohol swab was sufficient infection prophylaxis, and forgot to anesthetize the incision site, you were quickly shooed away by the attendings. Not that I was too thrilled to put a chest tube in a patient with a known TB + effusion, but hey them's the risk.
Bottom line: Your effort level and efficiency will determine what you get to do. Myself and another person in my medicine class definitely broke the ceiling for number of procedures, but we were aggressive and prepared and yet the other residents in our class still got a fair number of procedures.
For either a medicine or surgery prelim, you need to do a thorough investigation to determine if you will actually be allowed to function as a working, thinking physician, or if you will be use as a filler to bridge the gap for work needs and to keep the categorical residents under the 80 hour work week. I have found the latter to be less common with medicine prelim years based on what I have seen and heard from the subsequent CA classes here and from what I have heard from my connections with other chief residents at other programs.
On the spectrum of prelim years, Jim, yours is definitely at or near the top, but likely more due to your personality, level of skill and intelligence, and aggressiveness. If you can say that every or most of the interns in your class had the same experience, then I would say that your internship site was/is a jewel (and that may or may not also reflect the number of interns in your class - less giving you more opportunities to do procedures).
For the medicine prelims as a whole, it would be difficult to have you function solely as a stopgap because you cannot order tests, write for meds, examine and diagnose patients, admit/discharge patients, etc. if you don't develop their ability to recognize and treat a wide variety of pathologies that you will see. In that sense, I feel that medicine provides you with a greater breadth and depth of understanding of pathology and physiology. Not to say that rheumatology will be of great use to you in the future, but solid foundations in nephrology, cardiology, pulmonology, ID, GI, and endocrinology are all applicable to anesthesiology and can definitely help you avoid disasters through a deeper preoperative understanding of individual patient's global concerns, as well as helping to guide your intraoperative and postoperative therapy. Procedures in a medicine prelim year will depend largely on the size of the service and your willingness to do the procedures ("Hey intern X, I want you put in a central line, but if you aren't comfortable or don't have time, consult general surgery or interventional radiology.")
You struck a home run with your internship, but you are less likely to strike out with a medicine year in my opinion.
