At loggerheads with my senior - Need advice!

[bbg1951]

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I'm posting this message from my husband's account, and am in need of advice.

I am an intern with 2 residents above me, a 2nd year and a 3rd year. Our group has a total of 5 interns, of which, I am the only categorical and the others are TYs.

The 2nd year resident had his first year ICU rotation last month, and was put on as a senior in the ICU this month. I have had many difficulties working with him over the past few weeks, and have scheduled a meeting with him tomorrow so that we may improve communication between us. Him and I have many rotations together during this year, and I have no way of avoiding him.

During my 2nd day on nights, (probably my 5th day as a resident) he went MIA until 4 AM. I paged him 3 times with questions, and got no call back, so ended up spending loads of time on the phone with the pharmacy. He came back at 4 because of a new admit. The same night, we had a surgery that required clearance from us, and he wanted me to look up the clearance parameters. When he came up, he lectured me about not having them ready., I explained that I was still working on the other things that I had paged him about, and hadn't had time - at which point he lectured me for being inefficient. I requested him to manage the clearance, since he had just woken up and knew the parameters. I was still busy handling other orders, but he insisted I look up the parameters, and figure out how to give clearance.

On another occasion, after a code, we needed to put a line into the patient. He had some difficulty with the line and wouldn't let me assist despite multiple requests. He preferred to wait 10-15 minutes for a senior to arrive, get into gown and cap, and then put the line.

Recently, during a code, he insisted on attempting to trach a pt that was awake with labored breathing. I expressed concern a few times that she shouldn't be trached, and may even aspirate if she gags, but he did not change his request or discuss with me after. Many people on the floor were not happy with his call, and one person reported to our attending.

He does not discuss our patients with us before rounds, and often has holes in his story during rounds. If I correct him during rounds or fill in the gaps, he gets upset. If he mentions a treatment protocol that I don't agree with in front of other people and I disagree, he gets upset. I don't have the opportunity to discuss these plans before rounds, because he doesn't discuss the patients with me before rounds start. This, of course, affects pt care. I do believe that I hurt his ego when I do this, but my intentions are purely for understanding and my own education, rather than to undercut him. I want the best for the patient. He has demanded that if I don't agree with something he brings up during rounds, I should approach him later - with evidence. He doesn't tell me why I'm wrong, just that I shouldn't speak when not spoken to.

Today, a consult came by to look at our pt, and she had not had a chance to read the pt's history. I was also new to the case, but had a basic background on the pt. I went to stand next to my senior and the consult in hopes of gaining some insight. While looking at the screen, she asked for some info. He said "ummmm" and started logging into his EMR. I figured he didn't know, either, so tried to help him out by giving her the basic HOPI. He took me aside soon after and said I had no right to speak, and I should just stand and listen. He threatened to not be so nice and polite the next time I speak out of turn.

I realize it is in my best interest to keep my mouth shut and avoid him, but I can't do that for a year. Also, I would like to find a way to improve communications between us so that we may work effectively.

I have superficially mentioned it to my team leader and another senior, but not officially or in depth. Yesterday, I started this conversation with my 3rd year, but I'm afraid to sound like a complainer and not be taken seriously. Or, worse, be taken as someone who causes trouble. Who else should I speak with? Attending/Team Leader/Chiefs/Director??

How do I approach the conversation with my 2nd year senior?

 

[AStark]

Oookay. I gather you're an IM intern. I'm an R3. I suppose I was officially a senior as an R2, but certainly there's a huge difference in my experience, knowledge, and abilities since last summer. It's a fairly dramatic difference, really, and a year ago I didn't feel altogether confident or as competent as I felt I should have been to be a "senior". How things change...

I am an intern with 2 residents above me, a 2nd year and a 3rd year. Our group has a total of 5 interns, of which, I am the only categorical and the others are TYs.

The 2nd year resident had his first year ICU rotation last month, and was put on as a senior in the ICU this month. I have had many difficulties working with him over the past few weeks, and have scheduled a meeting with him tomorrow so that we may improve communication between us. Him and I have many rotations together during this year, and I have no way of avoiding him.

So is this an ICU rotation then? Whatever else I say here, it must be emphasized that you're an intern here, and hence you sit at the bottom of this particular totem pole. If you have no way of avoiding this R2, you're going to have to treat him as a senior. I'm not sure you have been.

During my 2nd day on nights, (probably my 5th day as a resident) he went MIA until 4 AM. I paged him 3 times with questions, and got no call back, so ended up spending loads of time on the phone with the pharmacy. He came back at 4 because of a new admit. The same night, we had a surgery that required clearance from us, and he wanted me to look up the clearance parameters. When he came up, he lectured me about not having them ready., I explained that I was still working on the other things that I had paged him about, and hadn't had time - at which point he lectured me for being inefficient. I requested him to manage the clearance, since he had just woken up and knew the parameters. I was still busy handling other orders, but he insisted I look up the parameters, and figure out how to give clearance.

If your senior asks you to do something, you do it. He should have the wherewithal to recognize that you might have been overwhelmed with other stuff, along with the fact that you were scarcely a week into residency, but I think you also need to recognize that he may have perceived you as being "argumentative". Not saying you were, but impressions can be created.

On another occasion, after a code, we needed to put a line into the patient. He had some difficulty with the line and wouldn't let me assist despite multiple requests. He preferred to wait 10-15 minutes for a senior to arrive, get into gown and cap, and then put the line.

Well, that is what it is. Have you done many lines? How would you have assisted?

Recently, during a code, he insisted on attempting to trach a pt that was awake with labored breathing. I expressed concern a few times that she shouldn't be trached, and may even aspirate if she gags, but he did not change his request or discuss with me after. Many people on the floor were not happy with his call, and one person reported to our attending.

I'm not sure I can make sense of this scenario. Are you saying he was attempting a emergency cricothyrotomy? Tracheostomy is not an emergency procedure. Neither are indicated for "laboured" breathing. Why is an R2 doing this anyhow? This would have to be "can't intubate, can't oxygenate" scenario for this to make any sense.

He does not discuss our patients with us before rounds, and often has holes in his story during rounds. If I correct him during rounds or fill in the gaps, he gets upset. If he mentions a treatment protocol that I don't agree with in front of other people and I disagree, he gets upset. I don't have the opportunity to discuss these plans before rounds, because he doesn't discuss the patients with me before rounds start. This, of course, affects pt care. I do believe that I hurt his ego when I do this, but my intentions are purely for understanding and my own education, rather than to undercut him. I want the best for the patient. He has demanded that if I don't agree with something he brings up during rounds, I should approach him later - with evidence. He doesn't tell me why I'm wrong, just that I shouldn't speak when not spoken to.

It's not your role to correct your R2. If there are problems with this R2's performance, that is for his senior and for the staff to assess. Asking questions is important. Making a point of correcting him is absolutely not doing yourself any favours here. Whether you are intending to undercut him isn't really relevant - it certainly sounds like you are.

Today, a consult came by to look at our pt, and she had not had a chance to read the pt's history. I was also new to the case, but had a basic background on the pt. I went to stand next to my senior and the consult in hopes of gaining some insight. While looking at the screen, she asked for some info. He said "ummmm" and started logging into his EMR. I figured he didn't know, either, so tried to help him out by giving her the basic HOPI. He took me aside soon after and said I had no right to speak, and I should just stand and listen. He threatened to not be so nice and polite the next time I speak out of turn.

I would recommend not trying to "help" this R2 again. It clearly is not wanted and it's not obvious to me that it's needed either.

I realize it is in my best interest to keep my mouth shut and avoid him, but I can't do that for a year. Also, I would like to find a way to improve communications between us so that we may work effectively.

Stop undercutting him. Don't contradict or "disagree" with his plans on rounds. That's the R3's (and the staff's) job. Not the intern's. I'm not saying that you should buy into this hierarchical structure, but this R2 might feel insecure about his position. It seems like much of what you're saying and doing is getting under his skin, whether you intend to or not. It doesn't sound like he's being all that professional, but it won't be the last time you encounter someone like that in residency or practice, and you need to learn to deal with that effectively.

I have superficially mentioned it to my team leader and another senior, but not officially or in depth. Yesterday, I started this conversation with my 3rd year, but I'm afraid to sound like a complainer and not be taken seriously. Or, worse, be taken as someone who causes trouble. Who else should I speak with? Attending/Team Leader/Chiefs/Director??

How do I approach the conversation with my 2nd year senior?

I don't know that there's any great remedy for this. Focus on your own learning and competencies. This isn't like a simple workplace conflict, as you are very new and very inexperienced. One way or another, this R2 finished his intern year and might be finding the transition to senior stressful. Because it is. So I don't think you're going to gain anything but trying to "improve your communication" with him.

 

[link2swim06]

Avoid disagreeing. You are just making your life a lot harder.

 

[Raryn]

I'm posting this message from my husband's account, and am in need of advice.

I am an intern with 2 residents above me, a 2nd year and a 3rd year. Our group has a total of 5 interns, of which, I am the only categorical and the others are TYs.

Similar to the above poster, given the structure of your team and the fact you have TYs, I'm going to hazard a guess that you're in an IM program.

The 2nd year resident had his first year ICU rotation last month, and was put on as a senior in the ICU this month. I have had many difficulties working with him over the past few weeks, and have scheduled a meeting with him tomorrow so that we may improve communication between us. Him and I have many rotations together during this year, and I have no way of avoiding him.

Introduction: The R2 just had an ICU rotation last month, and fresh from that experience he is now a level higher. You on the other hand, have been a resident for <1 month.

During my 2nd day on nights, (probably my 5th day as a resident) he went MIA until 4 AM. I paged him 3 times with questions, and got no call back, so ended up spending loads of time on the phone with the pharmacy. He came back at 4 because of a new admit. The same night, we had a surgery that required clearance from us, and he wanted me to look up the clearance parameters. When he came up, he lectured me about not having them ready., I explained that I was still working on the other things that I had paged him about, and hadn't had time - at which point he lectured me for being inefficient. I requested him to manage the clearance, since he had just woken up and knew the parameters. I was still busy handling other orders, but he insisted I look up the parameters, and figure out how to give clearance.

He was MIA. This is possibly inappropriate, though he's a senior in the ICU at night and has 1,000,001 issues that he could have been dealing with. Do you know for certain he was sleeping? In addition, is he on night float or is he doing 28 hr shifts? If it's a 28 hour shift and somewhat slow at 1-4am (i.e. no admissions and the only questions pressing are ones that can be answered by a call to pharmacy), it is entirely possible that even if he was sleeping it was not inappropriate. My program has done away with interns in the ICU at night because in this day and age, it's entirely too busy with entirely too high of an acuity to have to have brand new people who need that close supervision around.

Cardiac clearance is usually not an emergency at 4am, so he may have expected that you should be able to get to it in a reasonably time fashion. Pushing work *up* the foodchain is something that should be done only in the rarest circumstances. Sounds like he wasn't the most diplomatic and that was wrong on his part, but I wasn't there.

On another occasion, after a code, we needed to put a line into the patient. He had some difficulty with the line and wouldn't let me assist despite multiple requests. He preferred to wait 10-15 minutes for a senior to arrive, get into gown and cap, and then put the line.

Wait. Stop. So your senior, who has done at least one full ICU rotation last month (as well as goodness knows what other rotations during the 11 months previous) was having trouble with a line, and you're offended that rather than ask you, the brand new R1 for help, he preferred to wait 10-15 minutes for an R3? What? How many lines have you put in and how did you feel you were going to help? When I have trouble with a procedure, I usually try to find someone who has done *more* of them than me, not fewer.

Recently, during a code, he insisted on attempting to trach a pt that was awake with labored breathing. I expressed concern a few times that she shouldn't be trached, and may even aspirate if she gags, but he did not change his request or discuss with me after. Many people on the floor were not happy with his call, and one person reported to our attending.

Recently, during a code, as the person running the code ("code" or rapid response?) he made an executive decision to obtain an advanced airway on a patient (trach?? are you sure you don't mean intubate? or crich? IM residents aren't ATLS trained so I doubt it was a crich, and basically only gen surg/some pulmonologists/ENT do trachs, and even that is usually in the OR or with bronchoscopy assistance). You, the intern, still with <1 month experience, who has almost certainly never run a code disagrees. Bringing up a point is fine, but your resident is free to disagree with you. So are the nurses, but as the most senior person there, his word goes. They are welcome to bring up their concerns to the attending. That said, respiratory distress is frequently a very legitimate indication to intubate someone *before* they lose conciousness and their pulse.

He does not discuss our patients with us before rounds, and often has holes in his story during rounds. If I correct him during rounds or fill in the gaps, he gets upset. If he mentions a treatment protocol that I don't agree with in front of other people and I disagree, he gets upset. I don't have the opportunity to discuss these plans before rounds, because he doesn't discuss the patients with me before rounds start. This, of course, affects pt care. I do believe that I hurt his ego when I do this, but my intentions are purely for understanding and my own education, rather than to undercut him. I want the best for the patient. He has demanded that if I don't agree with something he brings up during rounds, I should approach him later - with evidence. He doesn't tell me why I'm wrong, just that I shouldn't speak when not spoken to.

Today, a consult came by to look at our pt, and she had not had a chance to read the pt's history. I was also new to the case, but had a basic background on the pt. I went to stand next to my senior and the consult in hopes of gaining some insight. While looking at the screen, she asked for some info. He said "ummmm" and started logging into his EMR. I figured he didn't know, either, so tried to help him out by giving her the basic HOPI. He took me aside soon after and said I had no right to speak, and I should just stand and listen. He threatened to not be so nice and polite the next time I speak out of turn.

Sounds like a brand new senior resident that is getting used to his role and is getting pissed at it being challenged. He may be overwhelmed a little by it, but sounds from the above that you aren't particularly helping. Believe me, it's a hell of a lot worse when it's a brand new attending transitioning to their new role, because almost any point the residents make can be seen as a challenge to authority.

Look, when I was an intern (even when I was a medical student), I'd try to "help" and inadvertently piss people off because I appeared arrogant. It sounds like you're doing the exact same thing. Take a step back, do the work on your specific patients, and if there are holes in the residents presentation, let the attending sort it out. If something is going to be explicitly harmful to a patient during rounds and you have information that would be relevant, do quietly interject, but if it's a minor issue, just take your own pulse and count to 10.

I realize it is in my best interest to keep my mouth shut and avoid him, but I can't do that for a year. Also, I would like to find a way to improve communications between us so that we may work effectively.

I have superficially mentioned it to my team leader and another senior, but not officially or in depth. Yesterday, I started this conversation with my 3rd year, but I'm afraid to sound like a complainer and not be taken seriously. Or, worse, be taken as someone who causes trouble. Who else should I speak with? Attending/Team Leader/Chiefs/Director??

How do I approach the conversation with my 2nd year senior?

You can bring it up with your second year, but the way to do it is very, very carefully. One on one, you can apologize for their being any misunderstandings, state clearly that you were only trying to be helpful in all of the above situations with no malice, but you understand how it could have been taken by him. You can ask him to *educate* you about cases like what happened with the patient who had respiratory distress, and then you leave it alone.

 

[Winged Scapula]

Also please create your own account.

Its free and easy to do.

Multiple users on 1 account are not allowed and it puts your husband's account in jeopardy; in addition it creates confusion for the users when they see different stories/experiences etc. and attribute them to one user.

 

[deleted480308]

op, you need to know your role and do what you are told by your senior

 

[Trouble1234]

You are a brand new intern who just started residency. What makes you think you are smarter and know better than your senior? The more you know, the more you realize how much you don't know. Listen to your seniors and focus on learning more yourself.

 

[doc05]

.

 

[Doctor4Life1769]

OP, you sounded like a know-it-all.

 

[AStark]

I was thinking about this a bit more, so I will offer an experience of my own. On a recent away rotation in a big neuro/trauma/++academic ICU, I worked with an R1 who was something of an oddball. I suppose I was an R2, but as an elective resident I wasn't really in any position to do the "senior" thing. Anyway, at one point this R1 attempted to educate me about CVICU patients, namely about how they usually do fine with few complications. At this point I'd done two blocks of ICU already at home, and at our centre that invariably entails dealing with the CV wrecks (we had one week of double valves all of whom did badly...). I didn't really need an R1 who - obviously - had never done a CVICU block before telling me "how it is".

Another time he'd been carrying the Rapid Response pager. I was on call, but the usual practice was for the on-call to focus on the admitted patients during the day and takeover the pager later in the afternoon. This R1 had gone to see a rapid call, and had checked that the patient wasn't imminently dying/crashing. He handed me the pager (probably around 2:30 in the afternoon) and asked me to go up and finish the consult.

Now, it's bad form to start seeing a patient and expect someone else to finish the job (like, oh, writing a note). It's absolutely ridiculous to expect your senior to do your work for you. So I told him that he should probably go back and finish his assessment and review it properly with staff. He made some excuses about having a bunch of other notes to write, needing to "grab a bite" (!), etc. I said "ok" and went to see the patient myself (turned out to be pretty interesting in the end). Another R2 observed the whole interaction and told me that he saw me put on my "senior hat" during it. In any case, another part of being a senior is making note of every little detail of questionable behaviour and having it feed back at the appropriate time. If I had been further involved in that R1's evaluation, you can bet I would have mentioned it (and I certainly have in other situations).

Recently, during a code, he insisted on attempting to trach a pt that was awake with labored breathing. I expressed concern a few times that she shouldn't be trached, and may even aspirate if she gags, but he did not change his request or discuss with me after. Many people on the floor were not happy with his call, and one person reported to our attending.

I still can't make sense of this. If this was a real code, I can't imagine how the patient would be awake and/or not requiring an advanced airway. I can only assume that by "trach" you mean "intubate", which makes it clear that "you don't know what you don't know" and have no business commenting on stuff like this. And you're right, aspiration is always a risk with intubation, but it's also a risk without a secure airway. It's also generally safer to try an "awake look" in these peri-arrest situations than to barrel ahead and do an RSI. How would you manage this patient?

 

[Doctor4Life1769]

I dunno how someone can confuse a trach with an intubation.

I knew the difference between the 2 from watching Scrubs and I was a college pre-med at that time.

Seriously, the OP has no business acting arrogant and attempting to undermine her senior without knowing something so fundamental like that. Just keep your head down, cross-cover like a good monkey that you are, and try to help out your senior.

 

[OneoftheGuptas]

Hello! I'm posting from my own account now. I posted from his last night, because I was having trouble logging into mine and was in need of advice right away. Thank you all for your replies!

I understand what everyone is saying. You're all right on many points. I completely understand that he must be overwhelmed, and it must be very difficult for him to have his authority/knowledge challenged. Also, I know close to nothing. I am not helping by interjecting my opinions or questioning him. Today, when we speak, I will apologize and let him know that I never meant to be insulting or step on his toes. I plan to also ask him what he expects of me.

About the code/rapid response situation, I sincerely apologize for the confusion. It was a rapid response, and he wanted to intubate. The patient had a regular pulse and good oxygen sats, she was being bagged. Her breathing was improving rather than getting worse, and she was fighting the intubation by biting down. It's not something I want to discuss to death, and the attending later told us it shouldn't have been attempted.

I'm not very intelligent, and I have very little confidence in the knowledge that I do have. I don't disagree with him, but rather ask him why he is choosing a certain course of management. I can understand that is ruffling his feathers, and will avoid doing it in the future.

About the line placement, I also have very little experience at that. I probably wouldn't have gotten it in. However, he didn't give me a response as to why he didn't want me to try. He just kept shaking his head and saying "no". I have no issues with being told that it's a difficult placement and we need help from someone more experienced. I don't like that he expects me to follow blindly without questioning or understanding.

The night duty was a 30 hour shift. I know he was sleeping, and have no issues with that. I have a problem with him not responding to pages and then yelling at me for being inefficient with my time, even when I'd given him a huge run down on what had been happening.

After rounds, our 3rd year consistently tells us to check the orders that the 2nd year has put in during rounds, because the 2nd year has a habit of putting them in the wrong pt, putting them incorrectly, or not putting them at all. On more than one occasion, he has fought with the respiratory therapists, nurses, and co-residents. One of my co-interns had an argument with him earlier this week. I'm saying this only to validate myself, to explain that I'm not the only one having issues. He is just a bit awkward, and seems to lack respect for anyone that is equal to or under him.

However, you are right. He is senior to me, and I need to adapt accordingly to make my life easier.

 

[OneoftheGuptas]

Hi guys, I wrote that reply yesterday, and had some difficulty with the internet connection, so wasn't able to post it. Anyways, a lot of stuff happened yesterday between this senior and other staff, and the 3rd year was having meetings with the chiefs about him. I can understand how I have come off, but really, that's not the case. Other co-interns and co-residents have been having difficulties with him, as well.

I thank you all for your input, and will try to post a more detailed reply later on today or this weekend.

 

[deleted480308]

I can understand how I have come off, but really, that's not the case. Other co-interns and co-residents have been having difficulties with him, as well.
.

Just for your own development, don't let other people having problems with this person take away your learning opportunity. You were wrong. Tell the senior that and apologize, then be better.

Your senior's problems with others don't change yours.

Apologizing can be difficult, never hurts to get the practice in when you earned the practice

 

[22031 Alum]

Your senior may be having issues, but he still knows more than you just by virtue of getting through a year of residency. It's your job to learn and accomplish tasks needed for patient care- not correct him or fix his issues. Do not feel emboldened by seeing or hearing about chiefs/attendings do the correcting- that's their job, not yours. You obviously have plenty of your own learning to do.

 

[SouthernSurgeon]

The other night when I was really having a hard time getting a line, the first thing I thought was, "man I could really use an intern right about now"

As for the intubation...sometimes when you are the one there, the one running the code, you have to make the call. 99 times out of 100, I'd rather intubate someone who might not have needed it than not intubate someone who did. Everyone else can monday morning quarterback all they want, but they weren't the one there making the decision.

--

On a more serious note, if you find yourself on a rotation with a weak senior...your only job for that month is to survive with your own reputation intact. Keep your head down, get your work done, always have a positive attitude. Don't get into arguments. Don't badmouth this senior to others. As said above - your job is not to fix him. Focus on your own learning.

 

[rokshana]

About the line placement, I also have very little experience at that. I probably wouldn't have gotten it in. However, he didn't give me a response as to why he didn't want me to try. He just kept shaking his head and saying "no". I have no issues with being told that it's a difficult placement and we need help from someone more experienced. I don't like that he expects me to follow blindly without questioning or understanding.

The night duty was a 30 hour shift. I know he was sleeping, and have no issues with that. I have a problem with him not responding to pages and then yelling at me for being inefficient with my time, even when I'd given him a huge run down on what had been happening.

if you don't understand why a senior (who no doubt has done enough lines to be certified to do them by himself) who is having difficulty doing a line placement does not ask the 2 week old intern to help with a line, then you either have a exaggerated belief in your abilities ( and there is nothing more scary than an overconfident intern...they can kill people) or no clue...either way seems like you need an attitude adjustment..before it gets YOU in trouble...

and as many others here have said, the issues your senior is having with HIS seniors is not yours to fix (or point out)...sticking your nose in his business will only blow back on you...keep your head down, do your work, and bite your tongue when you are tempted to correct your senior in any public encounter...really have a question about a plan, a procedure, etc, ask in private and ask it in way that suggests your curiosity and not your judgement.

and as far as the 30 hour shift....you as an intern have not had the pleasure of doing a 30 hour shift...you have no grounds to judge him...if he is not answering pages you can make mention of it in your evaluation of him if you feel the need...his job as a senior is to give you feedback(such as being inefficient) so the problem can be fixed...be thankful that he is giving you it early...many don't get the feedback until they are in front of the resident promotion committee and at that time it may be too late to fix...

 

[TraumaLlamaMD]

If someone with more experience has already tried and failed to place a line, the only thing you're going to accomplish by letting a less experienced person try is to increase the patient's risk of pneumothorax, hemorrhage, etc. It's not the kind of thing where you can just say "why not let the intern try, it can't hurt" - because it could hurt.

Procedures are very rarely a thing that would be kicked down a level, if you will.

 

[anonperson]

I can just imagine this stressed R2 trying to put in a line on a morbidly obese dehydrated DKA patient and having trouble while you're chirping in the background wanting to take a crack at it having been a doctor for a whole 2 weeks.

 

[AStark]

Sounds like you've gotten the message from us. But still need to address this:

About the code/rapid response situation, I sincerely apologize for the confusion. It was a rapid response, and he wanted to intubate. The patient had a regular pulse and good oxygen sats, she was being bagged. Her breathing was improving rather than getting worse, and she was fighting the intubation by biting down. It's not something I want to discuss to death, and the attending later told us it shouldn't have been attempted.

I will say that if the patient could be bagged effectively, it would have been reasonable to deepen the induction to optimize conditions for intubation. However, she might have been fragile enough hemodynamically that she wouldn't have tolerated more drugs. I can't really say since I wasn't there. But an "awake look" is always a lot safer regardless, and should be the default approach in an unstable patient.

 

[Law2Doc]

I agree with the posters above who suggest that the fact that this guy isn't a great senior doesn't really vindicate anything else written here. The thought of an intern trying to push tasks upward, showing up a senior in front of the attending and wanting to show him up on a line probably rub every more senior person the wrong way. As for the senior being MIA, I think this is a good learning experience for you. If you just needed him for things you could figure out with the pharmacy then it was inappropriate to call him in the first place. He's supposed to be available when you get over your head, not hold your hand and save you from looking up things. Most of the interns I worked with were careful to not call our senior if there was another option that didn't jeopardize patient care. When on call, you are the doctor, he is the backstop. Until it becomes a rarity for you to call anyone during your shift you aren't really pulling your weight. As for intubation, as mentioned above, its far worse to intimate too late than too early. It's much easier to take a tube out than to get a guy who has stopped breathing back.

 

[doc05]

About the code/rapid response situation, I sincerely apologize for the confusion. It was a rapid response, and he wanted to intubate. The patient had a regular pulse and good oxygen sats, she was being bagged.

This demonstrates that you don't know enough. Sounds like she needed to be tubed. "Bagging" a patient is never a good thing, and oxygen sats are not enough.

and the attending later told us it shouldn't have been attempted.

unless the attending was at the bedside, his opinion is worth nothing.

You can never go wrong preemptively intubating a sick patient.

 

[Doctor4Life1769]

The patient could have benefited from having anesthesia intubate using some paralytic, nonetheless, thats not the point.

The intern prolly paraded in her panties when she heard the news. Don't worry barbie, you're up next.

 

[Raryn]

The patient could have benefited from having anesthesia intubate using some paralytic, nonetheless, thats not the point.

The intern prolly paraded in her panties when she heard the news. Don't worry barbie, you're up next.

Medicine intubates with sedation and paralytics on the floors all the time. I do at least.

 

[AStark]

unless the attending was at the bedside, his opinion is worth nothing.

You can never go wrong preemptively intubating a sick patient.

Hard to say without knowing the details of the situation or the competencies of those involved. Unless it's completely urgent (and, in this case, it sounds like the patient was easily bagged), I review stuff like this with staff first (especially as an early R2!), even if it's just to say "This is my plan" and to hear "Ok".

Medicine intubates with sedation and paralytics on the floors all the time. I do at least.

Depends on the centre. I'm not sure most IM residents at my centre could pick the right drugs let alone troubleshoot an airway.

 

[22031 Alum]

Hard to say without knowing the details of the situation or the competencies of those involved. Unless it's completely urgent (and, in this case, it sounds like the patient was easily bagged), I review stuff like this with staff first (especially as an early R2!), even if it's just to say "This is my plan" and to hear "Ok".

You have a point, but I think we can all agree that a week 3 intern who thinks "intubate" and "trach" are synonyms isn't the person to be judging the choices made in that situation.

 

[AStark]

You have a point, but I think we can all agree that a week 3 intern who thinks "intubate" and "trach" are synonyms isn't the person to be judging the choices made in that situation.

Indeed we can.

 

[Doctor4Life1769]

Medicine intubates with sedation and paralytics on the floors all the time. I do at least.

Gotcha, every program is different. Some places don't allow medicine to intubate with paralytics

 

[AStark]

That doesn't make any sense. Either someone is competent and can make appropriate drug choices or they're not. Presumably such a policy reflects a lack of confidence in their judgement? In which case, maybe they shouldn't be doing advanced airway management...

 

[Raryn]

Gotcha, every program is different. Some places don't allow medicine to intubate with paralytics

That's just odd. Everywhere I've ever been either medicine can intubate, in which case they can use any tools they need to to do so, or medicine is not allowed to intubate at all, in which case they don't. Limiting attempts to no paralytics makes zero sense, especially given the fact that evidence shows routine paralysis improves almost every outcome with intubations. I mean, I'll usually take a look with just sedation as well in case it's a clear view that way, but if it isn't, suboptimal attempts without paralysis just makes things more difficult for everyone moving forward.

I always find it bizarre that a field with much less procedural comfort overall feels the need to be so machismo about the airway.

If I have a patient who needs to be tubed, I call a professional.

The people whom medicine are intubating are usually in acute situations 2/2 codes or severe respiratory distress. Anesthesia isn't always in house, and even where they are, not every institution has anesthesia routinely going to codes. If neither I nor the RT can get the tube in such an emergent situation, of course we call backup, but I'm not routinely waiting 30 minutes for someone else to come in when I'm the only physician in the hospital outside the ER overnight. I've done enough intubations to feel comfortable with most routine patients, and enough to recognize when I'm completely out of my element (c-spine injuries, absolutely tenuous patients who need to be intubated semi-emergently but I *do* have 30 minutes to wait, etc). Even then, I'll call the anesthesia provider to stand next to me, but I prefer trying the tube for experience. If it's during the daytime, I have PCCM fellows/attendings for backup, and at least here at my program they're perfectly comfortably with all aspects of the airway and routinely do intubations of all kinds and even have dozens of perc trachs by the time they graduate (30+ a year each for tracheostomies). I know that on the east coast, even pulmonary doesn't touch intubations all that much, which I find strange.

Mind you, when I graduate I have very small chance of still doing my own tubes in most hospitals, but the same is true for my own lines and I still enjoy doing those while I can. Hell, the subspecialty I'm applying for really doesn't have all that much of an inpatient presence at all, but there's still some satisfaction from doing a procedure and doing it well while I still can.

Edit: And I think I figured out why OP was so confused. I mean, technically speaking, it is an endoTRACHeal intubation, right? 😉

 

[doc05]

Hard to say without knowing the details of the situation or the competencies of those involved. Unless it's completely urgent (and, in this case, it sounds like the patient was easily bagged), I review stuff like this with staff first (especially as an early R2!), even if it's just to say "This is my plan" and to hear "Ok"..

If you need to bag the patient, it's urgent.

And checking with your attending is a sign of weakness.

 

[Law2Doc]

....Unless it's completely urgent (and, in this case, it sounds like the patient was easily bagged), I review stuff like this with staff first (especially as an early R2!), even if it's just to say "This is my plan" and to hear "Ok"...

Where I did intern year an R2 probably wouldn't hear "Ok" unless it was during business hours. You would most likely hear something like -- "WHAT THE F&(& are you doing calling me at 3 am for this?! You are the doctor and are looking at the patient. If you legitimately think he's cronking and needs to be intubated then you F())(&(*&ng intubate him and F@#$^#ng talk to me about it in the g!@$$@#@ morning! C'mon man, this is why we have you seniors physically present on the floor -- intern year is over!". 🙂.

 

[Perrotfish]

Where I did intern year an R2 probably wouldn't hear "Ok" unless it was during business hours. You would most likely hear something like -- "WHAT THE F&(& are you doing calling me at 3 am for this?! You are the doctor and are looking at the patient. If you legitimately think he's cronking and needs to be intubated then you F())(&(*&ng intubate him and F@#$^#ng talk to me about it in the g!@$$@#@ morning! C'mon man, this is why we have you seniors physically present on the floor -- intern year is over!". 🙂.

We went to very different institutions and yours sounds dangerous and awful. In most hospitals I have rotated through the ICU attending is physically present overnight unless there is a fellowship program, in which case the fellow is the one in house. In the one ICU I rotated through that had neither a fellow nor an attending in house it was made very clear that we would have the attending on the phone if we were going to need to manage an airway, or anything similarly emergent, if it was at all possible. An R2 who just intubated someone/placed a central line/whatever would need to have a truly amazing justification (I couldn't bag him and neither could the RT and anesthesia couldn't come) or he would be immediately failed.

Its a reasonable expectation of patients that their providers will be directly supervised until they are somewhat close to completely trained. On the floor, an R3 certainly meets that expectation and an R2 arguably does, since he's only 2 years away from practicing independently (though until midway through R2 I believe that they should call attendings liberally). In the ICU an R2 is 5 years away from being competent to practice independently. An R2 running the ICU without supervision is exactly the same as an MS3 running the floor without supervision. Its horrifying.

 

[Perrotfish]

BTW I think that people are getting too caught up in the distractors in the OP's post (intubation, central line, arguments on rounds) and are missing the main problem: senior not returning pages. To me that's pathognomonic for a dangerous senior. You can answer pages and quickly triage them out and be an OK senior. You can answer pages and be kind of a dick and be an OK senior. You can't just not answer pages. If the Intern is paging over an over again and isn't getting any answers then the Intern has a weak senior. If he wasn't answering because he was asleep the he's a weak and negligent senior. That needs to get reported, if it happens so much as one more time. If only because the Intern will eventually make a mistake due to lack of supervision, and then no one will be sympathetic that were getting stuck managing the hospital without supervision.

 

[22031 Alum]

BTW I think that people are getting too caught up in the distractors in the OP's post (intubation, central line, arguments on rounds) and are missing the main problem: senior not returning pages. To me that's pathognomonic for a dangerous senior. You can answer pages and quickly triage them out and be an OK senior. You can answer pages and be kind of a dick and be an OK senior. You can't just not answer pages. If the Intern is paging over an over again and isn't getting any answers then the Intern has a weak senior. If he wasn't answering because he was asleep the he's a weak and negligent senior. That needs to get reported, if it happens so much as one more time. If only because the Intern will eventually make a mistake due to lack of supervision, and then no one will be sympathetic that were getting stuck managing the hospital without supervision.

I don't think the fact that the senior is weak is lost on any of us. But it seems like OP was expecting a cheering section for showing up this weak senior, and just isn't going to get it from this crowd. All the things you call distractors are actually glaring examples of just how much she has yet to learn. These examples are very rightly being pointed out, in my opinion, given how highly OP seemed to think of her own knowledge and skills.

 

[Doctor4Life1769]

That doesn't make any sense. Either someone is competent and can make appropriate drug choices or they're not. Presumably such a policy reflects a lack of confidence in their judgement? In which case, maybe they shouldn't be doing advanced airway management...

To be honest, apparently in the past there was some issue related to someone pushing a paralytic. I assume either they couldnt intubate or the patient went into V-fib arrest from succ induced hyperkalemia.

That situation pre-dates me, and I totally agree. The medicine folks don't tend to intubate, it's usually RT and they arent giving sedation unless agreed upon by medicine and paralytics are only given when anesthesia is there. It's just odd but you play in the sandbox you're a part of.

 

[Doctor4Life1769]

Where I did intern year an R2 probably wouldn't hear "Ok" unless it was during business hours. You would most likely hear something like -- "WHAT THE F&(& are you doing calling me at 3 am for this?! You are the doctor and are looking at the patient. If you legitimately think he's cronking and needs to be intubated then you F())(&(*&ng intubate him and F@#$^#ng talk to me about it in the g!@$$@#@ morning! C'mon man, this is why we have you seniors physically present on the floor -- intern year is over!". 🙂.

We went to very different institutions and yours sounds dangerous and awful. In most hospitals I have rotated through the ICU attending is physically present overnight unless there is a fellowship program, in which case the fellow is the one in house. In the one ICU I rotated through that had neither a fellow nor an attending in house it was made very clear that we would have the attending on the phone if we were going to need to manage an airway, or anything similarly emergent, if it was at all possible. An R2 who just intubated someone/placed a central line/whatever would need to have a truly amazing justification (I couldn't bag him and neither could the RT and anesthesia couldn't come) or he would be immediately failed.

Its a reasonable expectation of patients that their providers will be directly supervised until they are somewhat close to completely trained. On the floor, an R3 certainly meets that expectation and an R2 arguably does, since he's only 2 years away from practicing independently (though until midway through R2 I believe that they should call attendings liberally). In the ICU an R2 is 5 years away from being competent to practice independently. An R2 running the ICU without supervision is exactly the same as an MS3 running the floor without supervision. Its horrifying.

Agree with L2D, and I usually dont agree much with him.
Where I am, they say "call us if you need anything or something major for help..." but if you do, you better have a real goddamn good reason to wake them up else they will be pissed off.

Placing a line or tubing someone without a phone call leading to a failed rotation on the other hand, sounds pretty harsh. I do agree that our attendings like to get a call if something major happened (i.e. transfer to ICU or unexpectedly dead) but besides that.... you are the doctor.

 

[Perrotfish]

Placing a line or tubing someone without a phone call leading to a failed rotation on the other hand, sounds pretty harsh. I do agree that our attendings like to get a call if something major happened (i.e. transfer to ICU or unexpectedly dead) but besides that.... you are the doctor.

The problem with saying 'you are the doctor is that 'doctor' is not a useful generic term and hasn't been for a few generations. No Internist would be comfortable managing a labor deck because 'you are the doctor'. You're not an obstetrician, or even in training to be one. Similarly every Pediatrician/Internist/Family Medicine resident should not need to pretend to be boarded in Intensive Care because they are on the rotation. Either the ICU doctor, or a fellow training to be an ICU doctor, should be providing direct supervision.

Residency programs should be set up with the goal that, well before you graduate, you are independently doing anything you will be expected to do independently as an attending. Managing a floor, or a clinic? Yes. Managing Subspecialty or ICU patients? No.

 

[rokshana]

BTW I think that people are getting too caught up in the distractors in the OP's post (intubation, central line, arguments on rounds) and are missing the main problem: senior not returning pages. To me that's pathognomonic for a dangerous senior. You can answer pages and quickly triage them out and be an OK senior. You can answer pages and be kind of a dick and be an OK senior. You can't just not answer pages. If the Intern is paging over an over again and isn't getting any answers then the Intern has a weak senior. If he wasn't answering because he was asleep the he's a weak and negligent senior. That needs to get reported, if it happens so much as one more time. If only because the Intern will eventually make a mistake due to lack of supervision, and then no one will be sympathetic that were getting stuck managing the hospital without supervision.

no...that was (and is) not the point of this thread...the point is a noob intern thinking that she knows more than her senior, mostly because she knows that that particular senior is having issues with his senior...but as 22031 stated she was thinking she was going to somehow get kudos for her behavior.

and your program seems to give not enough graduated autonomy to their residents if there is a icu attending/ fellow in house and no responsibility is given to a resident until R3 if even then...they are going to be in a bit of a shock on july 1st after their residency when they are expected to be an attending and haven't had any autonomy during their residency to learn how to be one.

 

[22031 Alum]

You guys are all correct, you know. Different programs do things differently, either because of custom/tradition, or necessity, or volume. Your justifications are all correct to a degree, because every program justifies its own methods in a way that fits in with that worldview. So you have programs with more autonomy saying "You're the doctor," and they are right. While programs with more supervision are saying "You're not in charge yet," and they're right. It just depends on where you are.

Where I am now, it is custom for attendings to scrub with and closely supervise PGY3s doing a procedure that I did independently (attending in the next room) as an intern. Neither program would change the other's mind re: which way is right, because each is right for its own situation.

Tl;dr- nobody's way is the only right way.

 

[Perrotfish]

and your program seems to give not enough graduated autonomy to their residents if there is a icu attending/ fellow in house and no responsibility is given to a resident until R3 if even then...they are going to be in a bit of a shock on july 1st after their residency when they are expected to be an attending and haven't had any autonomy during their residency to learn how to be one.

Again, my program gave autonomy in all the things they are expected to be autonomous in after graduation. In clinic/nursery/ward beginning in R2 you are autonomous. Early on in R2 its not considered a bad idea to check in kind of frequently, but you're basically on your own and sign out to the attending during rounds/in the morning/at the end of clinic. In the PICU/NICU someone is providing direct supervision because, honestly, why would you be expected to run an PICU independently as an attending Pediatrician?

A good question to ask is, if you were the attending rather than the resident, would you be calling someone about this? If the answer is no, then you need to learn how to manage it without calling your attending. Obviously the attending on the floor at 3 a.m. is the final word on patient management. On the other hand, as an attending Pediatrician, do you honestly think I'm not calling the ICU doctor when I'm intubating the patient in septic shock? Or that I don't have the neonatologist on the phone when someone delivers a 26 weeker on my Labor deck? Is there any situation at all where I, as an attending, would be expected to manage things like titrating multiple pressor drips or high frequency ventilation? If I'm not considered competent to manage those things when I'm fully trained, why in the world would I be considered competent to manage them as a partially trained resident?

 

[Doctor4Life1769]

Again, my program gave autonomy in all the things they are expected to be autonomous in after graduation. In clinic/nursery/ward beginning in R2 you are autonomous. Early on in R2 its not considered a bad idea to check in kind of frequently, but you're basically on your own and sign out to the attending during rounds/in the morning/at the end of clinic. In the PICU/NICU someone is providing direct supervision because, honestly, why would you be expected to run an PICU independently as an attending Pediatrician?

A good question to ask is, if you were the attending rather than the resident, would you be calling someone about this? If the answer is no, then you need to learn how to manage it without calling your attending. Obviously the attending on the floor at 3 a.m. is the final word on patient management. On the other hand, as an attending Pediatrician, do you honestly think I'm not calling the ICU doctor when I'm intubating the patient in septic shock? Or that I don't have the neonatologist on the phone when someone delivers a 26 weeker on my Labor deck? Is there any situation at all where I, as an attending, would be expected to manage things like titrating multiple pressor drips or high frequency ventilation? If I'm not considered competent to manage those things when I'm fully trained, why in the world would I be considered competent to manage them as a partially trained resident?

Huh?
Of course you're consulting CC for a pt in multi-organ failure or severe ARDS requiring specific ventilator settings. That is completely different from waking up an attending at 0300 or whatever to ask for permission to intubate a hypoxic pt or to place a line on a septic pt, in both cases where they will likely crash if they havent

I typically dont consult PCC unless the pt is one of the 2 or both, above. I can manage my on vent settings and pressors ok.

 

[rokshana]

Again, my program gave autonomy in all the things they are expected to be autonomous in after graduation. In clinic/nursery/ward beginning in R2 you are autonomous. Early on in R2 its not considered a bad idea to check in kind of frequently, but you're basically on your own and sign out to the attending during rounds/in the morning/at the end of clinic. In the PICU/NICU someone is providing direct supervision because, honestly, why would you be expected to run an PICU independently as an attending Pediatrician?

A good question to ask is, if you were the attending rather than the resident, would you be calling someone about this? If the answer is no, then you need to learn how to manage it without calling your attending. Obviously the attending on the floor at 3 a.m. is the final word on patient management. On the other hand, as an attending Pediatrician, do you honestly think I'm not calling the ICU doctor when I'm intubating the patient in septic shock? Or that I don't have the neonatologist on the phone when someone delivers a 26 weeker on my Labor deck? Is there any situation at all where I, as an attending, would be expected to manage things like titrating multiple pressor drips or high frequency ventilation? If I'm not considered competent to manage those things when I'm fully trained, why in the world would I be considered competent to manage them as a partially trained resident?

sorry! don't know why i didn't realize you were peds...it does seem that the culture of peds is more supervision...L2D (as many of us are, including the OP) IM...autonomy seems to come earlier in training for IM residents...where i trained there was little difference in the responsibilities of R2 and R3 and we were responsible for the ICU overnight (neither icu fellow ir attending were in house) as residents...early in the year, it would be the R3 as the seniors, but by mid year, R2s were also the seniors as well...and yes, we would expected to titrate multiple pressors and adjust vent settings as a resident...but i think that is IM and surg moreso than peds.

 

[Raryn]

Our ICU has senior IM residents (at least one PGY3, the other either a 2 or a 3) in house only, with a fellow available via phone who can come in if they needto... and an attending for backup if we need further help. Two IM seniors with 35++ ICU patients between them, also running all codes, seeing consults on the floors, and admitting all ICU patients from the ED. Every night when I'm on that service, I intubate patients if necessary, do 2-3 central lines on average, admit patients if I need to, and manage the current patients through the course of any number of conditions. Sometimes if a pair of seniors are in over their head (an obscene amount of admissions, extreme difficulties with the ventilator, possible need for emergent bronchoscopy in the middle of the night), we'll call the fellow... but other than the situations that need emergent bronchoscopy, I've never heard of the attending coming in overnight. If I woke my fellow up every time I had to do a procedure overnight, I'm pretty sure I'd have a nice talking to by the third night I was on.

Mind you, no one has ever yelled at me for calling them... but that's because I know when to call and do so sparingly. The adage is always to call if you have any question you need to, but if you're comfortable managing a patient, do what you need to overnight.

 

[Doctor4Life1769]

Our ICU has senior IM residents (at least one PGY3, the other either a 2 or a 3) in house only, with a fellow available via phone who can come in if they needto... and an attending for backup if we need further help. Two IM seniors with 35++ ICU patients between them, also running all codes, seeing consults on the floors, and admitting all ICU patients from the ED. Every night when I'm on that service, I intubate patients if necessary, do 2-3 central lines on average, admit patients if I need to, and manage the current patients through the course of any number of conditions. Sometimes if a pair of seniors are in over their head (an obscene amount of admissions, extreme difficulties with the ventilator, possible need for emergent bronchoscopy in the middle of the night), we'll call the fellow... but other than the situations that need emergent bronchoscopy, I've never heard of the attending coming in overnight. If I woke my fellow up every time I had to do a procedure overnight, I'm pretty sure I'd have a nice talking to by the third night I was on.

Mind you, no one has ever yelled at me for calling them... but that's because I know when to call and do so sparingly. The adage is always to call if you have any question you need to, but if you're comfortable managing a patient, do what you need to overnight.

Do you guys staff ICUers over night with fellow? i.e. consults or admissions?

 

[Raryn]

Do you guys staff ICUers over night with fellow? i.e. consults or admissions?

Not unless we have questions regarding management of something unusual. If it's a typical sepsis/pneumonia/ards patient? I'll tube them, line them up, start the abx/fluids/pressors, and staff it in the morning.

 

[Doctor4Life1769]

Not unless we have questions regarding management of something unusual. If it's a typical sepsis/pneumonia/ards patient? I'll tube them, line them up, start the abx/fluids/pressors, and staff it in the morning.

Sounds like what we do.
Except, we aren't tubing them. Usually they come pre-tubed from ED or RT will tube. Its a shame, and I'm fully capable of tubing, but again I play in the sandbox I'm currently a part of.

 

[drkristy85]

As Peds, we get zero autonomy. In fact,at our program we have less autonomy than at Perrotfish's program. In clinic, the attending comes in for each pt and changes our management plan if they want. On floor wards, we have to staff each admit overnight with attending and also call them for decision making. They don't give any autonomy to the ward chief either. It is very frustrating. Meanwhile, our Med Peds residents fill us in on how much autonomy they get in IM (basically what u all stated above). It is very frustrating. We have all complained frequently and written it on our ACGME surveys. We had a huge meeting with attendings and residents to discuss the issue. At the meeting, we were basically told to shut up and deal with it. Us seniors don't know what to do anymore

 

[AStark]

Our ICU has senior IM residents (at least one PGY3, the other either a 2 or a 3) in house only, with a fellow available via phone who can come in if they needto... and an attending for backup if we need further help. Two IM seniors with 35++ ICU patients between them, also running all codes, seeing consults on the floors, and admitting all ICU patients from the ED. Every night when I'm on that service, I intubate patients if necessary, do 2-3 central lines on average, admit patients if I need to, and manage the current patients through the course of any number of conditions. Sometimes if a pair of seniors are in over their head (an obscene amount of admissions, extreme difficulties with the ventilator, possible need for emergent bronchoscopy in the middle of the night), we'll call the fellow... but other than the situations that need emergent bronchoscopy, I've never heard of the attending coming in overnight. If I woke my fellow up every time I had to do a procedure overnight, I'm pretty sure I'd have a nice talking to by the third night I was on.

Mind you, no one has ever yelled at me for calling them... but that's because I know when to call and do so sparingly. The adage is always to call if you have any question you need to, but if you're comfortable managing a patient, do what you need to overnight.

We don't have any fellows. Most of the residents coming through ICU are R2s, apart from anesthesia and EM who are R3s (though the EM people are 2+1 family ones...). You cover 12-14 ICU patients and up to another 8 in CVICU, along with any consults from the ED or the floor or sometimes the OR. We don't have that degree of turnover, but the CV patients can be really variable. Last week they had one day with four cases, two of whom had to go back. No fellows and you're by yourself, though sometimes there's a senior at home. The R2s come from various programs, but essentially none start with the skills to place lines independently let alone tube an unstable ICU patient.

But staff are often there late and will always come in if you want them too. Most also expect to be kept informed about what's going on. All consults/admissions must be reviewed with staff. Some also want to know about any "status changes" overnight, so the threshold for calling is usually low. At this point the staff generally trust my abilities and judgement, but if anything I want to call more now. Most of the time they don't have a lot to add, but it's important for me to get that feedback.

I think earlier on I felt like I should "be the doctor" and make calls independently, but I reviewed because that's what we were explicitly told to do as interns/juniors. Which only makes sense. Now I call mainly to solicit feedback on my decisions, not, I should add, to ask what I should do. But as learners with the opportunity to review, I can't see much downside to it.

 

[Raryn]

To that I would say get over yourself and recognize that it is the right thing for patients.

If it was your kid would you want some second year peds "senior" calling the shots?

And what happens July 1 three years in when that peds attending who has never made an independent decision in their lifetime is now the one in charge? Better for independence with backup available if needed and supervision of every decision even if it is after the fact rather than suddenly getting thrown in the deep end when you graduate.

My hospital the medicine program is very similar to as described above. It's a joke. IM residents with 4-6 weeks of critical care experience are simply not qualified to run a complex ICU overnight without the input of someone more experienced. Patients get either ignored if they are an existing player or mismanaged if they are a new admit.

This is not meant as a sleight against medicine; I wouldn't want my own PGY2s running a unit independently either.

For us, every new consult and every new admit gets staffed immediately with an attending surgeon. I can count on one hand the times they have changed my plan, but I still call. Their name is on the chart and they have the ultimate responsibility for the patient so that is fine. I still get autonomy - I took a PGY2 through his first colectomy last week while the staff watched - but patients still deserve to have an attending involved in their care.

I Have also had the hilarious situation arise numerous times of my staff calling the medicine attending at 2 AM from the bedside to discuss their patient. It always provokes a shock from the medicine attending who is home and hasn't heard a peep about their deteriorating patient.

I would also never tube, line, or transfer a patient to an ICU without calling the attending. Wouldn't change my management and I wouldn't delay doing it, but I still FYI them.

*Shrug*. Different cultures. You guys have a lot less autonomy as juniors and spend a lot more time in the ORs learning procedural skills, while our graded autonomy progresses at a different pace and the vast majority of our time is about medical management. I'd be worried if there were any of our PGY2s that couldn't manage a septic patient (the #1 diagnosis for our MICU). The attending/fellow are available if it isn't that routine, but the trust is there (with verification either the next day or with the attending reviewing results from afar just to keep an eye on things). It's obviously different for a brand new intern as opposed to a 2nd year halfway through the year or a 3rd year ready to graduate. Not to mention we usually have a second person around to bounce ideas off of and to realize when we're in over our heads. As I said above, our program at least always has at least one third year resident in the ICU at night, so it isn't just a brand new second year going off and doing things by themselves.

Can't say which is a better system, but I do have to say that our patients aren't "ignored" or "mismanaged" 99+% of the time and our residents are confident of their ability to practice competently when they graduate. Unlike general surgery, I've never heard of an IM "transition to practice" fellowship...