Being A Good Boss aka: Everything I Always Wanted To Know About Senior Residency.....

[NuMD97]

......But Was Afraid To Ask.

Ok, Folks. Question time: This is probably best addressed to the PGY-2's and PGY-3's (attendings as well?) out there in cyberspace. I've heard rumors that the second and third years are mostly just "clipboard" years where you supervise the interns and make sure that the work is getting done while in your spare time you teach the medical students. To those who have already lived through those years, any advice? Anything in hindsight you might have done differently had you known________? Any input would be duly and gratefully appreciated. Thanks in advance.

Nu

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[NuMD97]

No upper level resident wants to share his/her trade secrets? Really??

 

[NuMD97]

I thought this thread might be a stretch. But I was hopeful. I was sure there were a few PGY-2's, at the very least. No thoughts out there? I'm still curious.

 

[Winged Scapula]

I know of only one upper level resident (droliver, PGY-3) who posts with any regularity. I'm afraid you might be in for a long wait for a response to your query.

 

[NuMD97]

Thanks, Kim. That's what I suspected. Gee, you mean to say that I'm too old for this place?

 

[surg]

OK OK! You win!
Here are my thoughts...

1) Don't harass your interns when they are obviously trying. It is easy to forget what being an intern was like and fall into "When I was an intern..." Well you know what? You aren't anymore and the problems they face may be different from the problems you face.

2) All the patients are ultimately your responsibility. This flies in the face of #1, but the team looks to you as the chief or senior resident to make sure each patient has a plan and that the plan makes sense and that it is carried out. No amount of excuses that the intern should have done X, Y, or Z will change the fact that ultimately the attending will blame you.

3) Protect the team. Don't allow the attendings to take things out on the intern. You were the chief or senior on, act like it.

4) Be clear. Every intern hates a wishy-washy senior or chief. If you want something done a certain way, tell your intern, don't leave him or her guessing.

5) Discuss up front with your intern contingency planning. "If X happens, do Y" This will give your intern more learning, improve her awareness that X might happen and prepare her for the immediate response. Also be clear on when you want to be called, especially if it is for stuff that the intern can handle on their own in general (sometimes you just can't sleep unless you know that Mr. Jones's kidney transplant still makes urine before you go to bed)

6) In July and August, decide on a time that your intern will call you to run the service again with you (i.e. 10PM) before you go to bed. This will lower the stress of the intern in the sense that they know that they have a time to ask all the silly questions that don't merit a phone call all on their own, and it also encourages the compulsiveness that is necessary to make it through the first few months of internship when they really don't know what is going on.

7) You are not an intern. Pitch in for the good of the team, but don't duplicate work that the intern is doing anyway, you will drive yourself nuts and it will keep you in the hospital longer with no benefit to the patient.

8) Pay attention to the mood of the team. Get people out of the hospital when they aren't needed. Keeping people standing around the hospital doing nothing is stupid and ultimately counterproductive. If your case is running late, have a mid-level resident round and check in with them or the intern on when you get out to make sure everything is ok. The WHOLE team doesn't need to stay just to have a big showing at rounds.

more as I think of them.

 

[NuMD97]

Tough year, huh, Surg? But I do truly appreciate your taking the time. Like internship year, there are surely going to be "wish lists" that I would have liked to have had. Again, I thank you for making the effort.

Nu

 

[Winged Scapula]

•••quote:•••Originally posted by NuMD97:
•Thanks, Kim. That's what I suspected. Gee, you mean to say that I'm too old for this place? •••••Not at all...we need more residents around to assist with information and advice.

 

[NuMD97]

July 1st looms large. Perhaps I'm going about this all wrong: any med students want to add their thoughts about how residents can better serve their needs? I'm serious about this. I really want to create a happy team that is productive as well as one that meets the needs of all participants. Any thoughts will duly be appreciated.

 

[Tigger14]

As a new graduate, I can second what surg said. I am most scared of being junior to someone who can't be bothered to help or who does not give clear instructions. Especially in surgery, I am here to learn it, not because I know it already, and I have heard stories about interns being left to figure things out alone. Be clear and be kind, and your team will love you.

 

[NuMD97]

Thanks, Tigger. I appreciate your input. I've had some very special residents oversee me, and then again I've had "the other".

I think more than anything else, it's a question of balance. Kindness is without question a necessary component. I never ascribed to the philosophy that "we did it that way, and therefore you will have to, too." It's idiotic. Bottom line at all times is good patient care. And if we all have that goal in mind, the rest should be geared towards that. Ego has no place in team work. Just my humble opinion.

Again, thanks for your reply.

 

[NuMD97]

Any medicine folk want to weigh in now that we've heard from our surgery brethren?

 

[md03]

I'll weigh in with some student comments:

On my surgery rotation, we switched teams about a week before the residents did (to accomodate school holiday schedules). It really put me off that the residents (or attendings, for that matter) didn't go through the formality of exchanging names with the students on that first day. Maybe it was because we were only there for a week, and maybe it was because they were so fried. But it made them seem kind of rude, and every other rotatation I did started with an exchage of names.

If a student is having some kind of performance problem, talk with them about it privately and give them a chance to rectify the problem. We can't change what we don't know about, and may not realize there is a problem (at my school, more than one student has had a formal midmonth evaluation which didn't indicate any problems, only to have a horrible final evaluation)

I don't know how call works where you are, but at my school the students took overnight call q4. We could me on with any of the pgy1-4, as their schedules were not regular due to vacations and stuff. The higher level residents bascially just shooed us away, and only called us if there was a pt in the ER needing admission. Later, for example, I'd find out the resident was doing stuff like changing lines, fiddling with a swan, managing a HTN emergency, and running a code. When I said that I wished I had been called for some of that (I understand not being called for a code), they would say, Oh, it wasn't interesting and you wouldn't have learned anything.. I disagree... I beleive I could have learned from that stuff and could have been given the change to change a line, for example. Don't shoo away students who want to tag along and learn some of that stuff.

If at all possible, let students do cases!! Some of the chiefs as my school designated some cases as "Student cases" (I did the rotation in the second half of the year). These were things like removing portacaths, lipomas, abcesses, and guillotine amputations. Also don't automatically ban a student from scrubbing on a HIV or Hep B+ patient. They should get to if they want to.

 

[gherelin]

Hey NuMD,
From the tone of your posts that I've read so far, it seems like you will be a wonderful senior res. (Are you sure in you're in surgery???Sorry...)Since someone already gave you a great list of things to do, I'll share my humble opinion of what not to do, or at least, what I found offensive or difficult about other senior residents (in any specialty):
1. Please don't play favorites or let the other residents/students know who you think is an idiot and who you think is the greatest gift to hospitals. I watched a poor intern completely and constantly humiliated and talked behind his back last year by the senior resident. She constantly gave me his work to do because she didn't trust him, which left me feeling in the middle, and as if I was stealing his learning opportunities.
2. Allow people to make suggestions or even, egads, correct you, without taking immediate or long-term indirect revenge. (Harder said than done, I know.)
3. If you are in good with the nursing staff, encourage them to work well with your students and interns by demonstrating in front of the nurses your high opinion of them-praising them , bringing them into conversations, deferring to their judgement whenever possible, etc.
4.Share leadership/adminstrative responsibilities with students and interns as possible. In my opinion, the rigid hierarchy of hospitals has a lot to do with a lot of the dysfunction there.
Waah....my longest post yet. Hope I didn't bore you! Good luck NuMD, tho' I don't think it's really needed!

 

[NuMD97]

I agree with you, md03. It is beyond me why some attendings don't tell you mid-rotation that what you thought was a good one was in fact one of your worst. One attending knowingly told me that many play that game. It's a shame, because it defeats the purpose of really trying to learn and improve your skills.

And basic courtesy counts as well. I wholeheartedly agree with you. I used to begin a new rotation by telling my new med students not to worry, that they would not be responsible for my laundry nor my dry cleaning. That usually served to take the edge off their nervousness and set the tone for a positive experience. Another "older" intern and I once discussed the "system" at great length. Perhaps because we are not typical products of it, we see and do things differently. I personally won't perpetuate something that I view as harmful, just for the sake of "tradition." That's just plain idiotic. (Getting off my soapbox now, before I trip. )

Thanks for your input!

Nu

 

[NuMD97]

I've seen a lot of what you describe, gherelin. It's most unfortunate. As an aside, I've learned that a good nurse will often be one of your best instructors if you recognize the hard work that they do that goes unappreciated. Most will work with you if they recognize your sincerity.

As far as what I have seen, egos have no place in patient care. Unfortunately, it takes a front row seat often enough. I guess it's truly up to the team leader to set the tone. And yes, all members of the team should be equally included. I agree with you 100%.

Thanks for taking the time to answer my query.

 

[tussy]

I feel that the good seniors are the ones that make everyone feel like part of the team. They trust the judgement of the juniors and will let them work independently but will be there when their help is needed.

Good communication is key as well. You should talk to each member of the team and tell them what their responsibilities are and what you expect of them. This is especially true of the medical students as their responsibilities vary greatly from one service to another. Also, it is nice if you identify what the individual goals of the students are. Not every student wants to be a surgeon. Some may wish do anesthesiology and may be really interested in learning to do lines, whereas another might want to do internal med and may be more happy to sort of an electrolyte/acid/base problem.

Recognize the fact that although the clerks and interns don't have the same responsibility as you do, that it is a very stressful time for them. AS an intern i'm doing brutal call, and operating at the periphery of my knowledge most of the time. Don't belittle me and tell me that my job isn't that hard. That doesn't make me feel any better when i'm post call after a busy night.

Both positive as well as negative criticm is important and need to be balanced.

Request the team to give you feelback on your leadership of the team and things they feel you should do differently.

OK, that's it for my 5am ramblings before i head to the hospital for rounds. Goodluck.

 

[NuMD97]

Thanks, Tussy. As an aside, "belittling" is not in my character anyway.

 

[njbmd]

Hey there,
I will second and echo the things that Kimberli listed above. My best senior resident showed a little interest in my professional development and was willing to offer wisdom in helping me develop as an intern and get everything covered. She helped me learned to trust my judgement very quickly.

The best chiefs looked to make sure the whole team functioned well and that the service was well-covered. My best chiefs have been the ones who were most organized. When one intern had the day off, we all pitched in, not just me to handle everything.

Finally, I always appreciate good teaching. I am never going to be as experienced as the person above me. I am here for learning and I always appreciate the wisdom of my elders.

Do realize that if your chiefs are good and offering good teaching and leadership, the rest of the service will do the same. I remember rotating at a large city hospital that was covered by three medical schools. One of the senior residents was lazy and generally condescending to interns and medical students from another school. It affected the whole service and did nothing for morale. On the other hand, I was fortunate to have good senior residents who functioned well and got the job done. It made such a difference. I found myself pitying the folks on the other service and pitching in to help out when I could have been gone for the day.

In short, be a good leader and you will generally have good followers.

 

[Winged Scapula]

While I'd like to take credit for the things said above (as I've been quoted in njbmd's most recent post), I cannot. However, I agree with nearly everything said.

I cannot stress hard enough how important it is to be kind and be a team player. Interns, medical students and all other junior staff will work MUCH harder and complain MUCH less if they like and respect their Chief. I have personal experience with unpleasant, unkind and egotistical senior residents - my rotation was all the more miserable for it, the hours *seemed* longer (when they really weren't) and I couldn't wait to leave. Now, I might still want to leave as early as possible, but when I'm paired with a senior who remembers what its like to be clueless, tired and overworked and also works as part of the team, I'm much more willing to stay late without grumbling and to do extra things to make everyone's life easier. Business learned a long time ago that keeping the lackeys happy makes things more efficient. Medicine, and surgery, seem to have overlooked that lesson.

I also try and make sure all medical students are introduced, know the roles everyone plays (including themselves) and that we are happy to teach, talk about our careers or just generally socialize with them. And while I agree that much of the stuff we do probably has little educational value for students taking call with us (ie, if I'm just getting calls about so and so wanting something to sleep, etc. the student is probably better of reading), I draw the line at letting students do invasive procedures like changing lines (assuming we are speaking of central lines). For one, I need the practice. Secondly, lines - even changing them over a wire, are invasive procedures and not without complications (just ask the woman transferred here from another institution because the intern caught her IJ wire on her Greenfield filter and yanked it up a couple of inches). This is obviously a teaching institution but I am not comfortable enough with the procedure myself to hand it over to a student...I am more than happy to have them assist, or to do other things (ie, like insert Foley's, start IVs, etc.) but also think the senior residents would agree with me. This is a sore subject with some of us here because we had a student on service with us a few months back who loudly complained when we didn't allow him to do central lines. I relented and let him remove a chest tube because I felt comfortable handling the potential complication(s).

Anyway, it would be nice to hear from more senior residents...

 

[njbmd]

•••quote:•••Originally posted by njbmd:
•Hey there,
I will second and echo the things that surg listed above. My best senior resident showed a little interest in my professional development and was willing to offer wisdom in helping me develop as an intern and get everything covered. She helped me learned to trust my judgement very quickly.

The best chiefs looked to make sure the whole team functioned well and that the service was well-covered. My best chiefs have been the ones who were most organized. When one intern had the day off, we all pitched in, not just me to handle everything.

Finally, I always appreciate good teaching. I am never going to be as experienced as the person above me. I am here for learning and I always appreciate the wisdom of my elders.

Do realize that if your chiefs are good and offering good teaching and leadership, the rest of the service will do the same. I remember rotating at a large city hospital that was covered by three medical schools. One of the senior residents was lazy and generally condescending to interns and medical students from another school. It affected the whole service and did nothing for morale. On the other hand, I was fortunate to have good senior residents who functioned well and got the job done. It made such a difference. I found myself pitying the folks on the other service and pitching in to help out when I could have been gone for the day.

In short, be a good leader and you will generally have good followers.•••••

 

[NuMD97]

I appreciate all input. It's certainly given me a lot to think about before I start. I remember being on the cardiac care unit with one senior resident and casually she told me that we should check all I's & O's (one other confused intern wondered what about "eyes and nose"? ) before we went to bed the night we were on call together. Now, why couldn't this have been spelled out a lot earlier in the goals of the rotation?

I think besides "setting the tone", goals for each member should be spelled out for the duration of the rotation. How come what is basic is never entertained? I, for one, would have LOVED to know right up front, what was expected of me for each rotation, instead of just trying to figure it out for myself. Why the secret?

And you folks reminded me of the importance of setting goals for each patient daily. Things I need to consider to stay a step ahead of all junior folk.

Again, I appreciate all who took the time to answer my query. If anything else should be noted that we forgot to consider, I welcome your replies.

Nu

 

[tussy]

•••quote:••••originally posted by tussy: However, someone out there let us do our first chest tube and central line at one time.•••••

Sure...but NOT as a medical student. But essentially we agree - if the student is interested, shows that they know the risks and indications for a procedure and (most importantly), if I feel comfortable with the procedure and being able to handle any complications, I'll let a medical student do it.

Draining abscesses is a definite, as is starting IVs, Foleys, removing Chest tubes. But since I am not comfortable with central lines and chest tubes it will be awhile before I let a medical student do that.

 

[neutropeniaboy]

Well, here's what I would have appreciated most as a medical student from my residents:

A lot of residents gave me assignments such as article searches or talks on various surgical or medical subjects. That's fine. But what I wish residents had done was spend a lot more time teaching me the nitty gritty of floor management, small procedures, why we use this wrap v. the other, etc.

I think I really got shut out of a lot of good knowledge. The topics I could have done at home while preparing for the boards...

 

[NuMD97]

Originally posted by Neutropeniaboy:

•••quote:••• I think I really got shut out of a lot of good knowledge. The topics I could have done at home while preparing for the boards... ••••You reminded me. Early in September we all got "sat down" and read the "riot act" as it were by one of the co-program directors. To wit: that the department was receiving many complaints from the medical students that they were merely being "parked" in the library to "study" in the afternoon, and not being called upon to do anything. We, as interns, being still "wet behind the ears" yet didn't know where the boundaries were between us and the junior residents. We were looking at them to set the tone of the teams and not trample on anyone's feet. The co-program director told us at that meeting that the interns were responsible for teaching the third year medical students and the residents were supposed to be guiding the sub-I's. Who knew? And why were we not told of the formatting of the teams, say, at orientation, way back in June, at the same time that we received a lot of useless information that day?

No wonder they got so many complaints. Now, any medical interns want to check in with their thoughts?

 

[NuMD97]

One last thought:

From the medical point of view, any special considerations for one's role in the ICU/CCU/ER setting? Especially if no attendings are around.

Thanks once again for your input.

Nu

 

[docab]

One additional thought from a PGY3 (only a week to go!): No matter how much a new patient case seems like "a dump" or boring because you've had plenty of similar cases, always take the attitude that there's something to learn from each case. Interns are overworked and gettting admissions that feel like "dumps" just makes them feel like they now have more hospital work with nothing from it to gain. It's a horrible feeling. I've found the best way to keep my intern's spirit high is to say "I know it seems like a crappy admission, but I guarantee I'll find a teaching point in it for you." Then stick to your word! The teaching point may not have anything to do with the actual reason for admission. It may be on something in their PMH or med list. However, even with things as simple as pneumonia (ok, I'm an internist...!), you'd be surprised that most interns do not know the criteria of drug choices recommended in the lastest guidelines and why the recommendations were made. Sticking with this plan makes each admission have a learning value.

Overall, I've also learned that if the resident complains all the time, the whole team complains and feels miserable. If the resident takes a positive attitude (without losing the ability to recognize the frustrations of an intern), and gets an intern to laugh here and there, the days are much more tolerable.

 

[NuMD97]

Originally noted by Docab:

•••quote:••• If the resident takes a positive attitude (without losing the ability to recognize the frustrations of an intern), and gets an intern to laugh here and there, the days are much more tolerable. ••••Agreed. You are right. If one thinks it's just another ______ (fill in the blank with the most common reasons for hospital admission), you just may have lulled yourself into a false sense of complacency, and missed the key that makes this particular admission different. But even if routine, a patient deserves your full respect and attention.

Thanks for taking the time for your insight.