Concerns about junior residents

[VenusinFurs]

So, I'm in a family practice program that is unusually inpatient heavy, and as you all know we are fast approaching new intern season. I am currently the senior (at the end of my second year) working with two first year residents. Our census is typically 12-18. When the newbies come on, there are two of them, one second year, and one third year who is basically supposed to watch the newbies closely to make sure they don't kill anyone. The first years typically don't take more than 2-3 patients at first and the second year takes at least 8 to pick up the slack. My current duties are to see as many of the patients I can, particularly the sick ones, to pick up admissions while the first years are working, to work with the students, and to answer outpatient calls when the clinic is closed.

My second years just aren't where they should be. Their decisions are ok, but they seem to struggle with more than 6 patients and they've been asking me to pick up one or two of theirs. I have absolutely no problem with this, but if this is all they can do when they get to second year, we are ****ed. My co-second year residents have observed this is a problem with most of the first year class- they are either really slow or so haphazard that they miss big things.

I guess I'm mostly panicking and wanting to vent, but if anyone has any advice, I'm all for it.

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[doc05]

what to do?

don't help your juniors EVER. push them to get better on their own.

 

[VenusinFurs]

(I'm scared of confrontation is the real problem I think)

 

[VenusinFurs]

I think that's it, I just gotta tell them that it's tough but they need to get their **** done.

 

[Raryn]

Nothing will make them more efficient than getting thrown in the deep end when they're a brand new senior. I'm willing to bet the same thing happened to you. As long as your program has adequate supervision from more senior people and attendings come July, they'll probably be OK.

 

[rokshana]

So, I'm in a family practice program that is unusually inpatient heavy, and as you all know we are fast approaching new intern season. I am currently the senior (at the end of my second year) working with two first year residents. Our census is typically 12-18. When the newbies come on, there are two of them, one second year, and one third year who is basically supposed to watch the newbies closely to make sure they don't kill anyone. The first years typically don't take more than 2-3 patients at first and the second year takes at least 8 to pick up the slack. My current duties are to see as many of the patients I can, particularly the sick ones, to pick up admissions while the first years are working, to work with the students, and to answer outpatient calls when the clinic is closed.

My second years just aren't where they should be. Their decisions are ok, but they seem to struggle with more than 6 patients and they've been asking me to pick up one or two of theirs. I have absolutely no problem with this, but if this is all they can do when they get to second year, we are ****ed. My co-second year residents have observed this is a problem with most of the first year class- they are either really slow or so haphazard that they miss big things.

I guess I'm mostly panicking and wanting to vent, but if anyone has any advice, I'm all for it.

ya'll have FOUR people on an in pt service of 12-18? and your interns have 2-3 pts ...in JUNE? smh

tired is right...if you let the interns know that if they don't step up to the plate you will cover the work...they are going to take advantage of that...but ultimately the seniors did them a disservice...there should have been some graduated autonomy given through the year so by now, they should be de facto residents, chomping at the bit to be residents....and THEY should be doing the lion's share of the work at this point....because in less than a month they will have to...at this point you should be more in a supervisory role...since that should be your goal...to learn how to delegate and teach your interns so that you are comfortable in knowing that the work is being done by those under you...and that you learn that things can be done and done right without you having to do it yourself...

you may not be able to get them ready in this next month...but you should look to see what you can do as a 3rd year to get the next set of interns through the coming year so that next June you are not thinking the same thing...interns in june are a reflection of the guidance and training that they have received from their seniors...if they are not ready by june, well...

 

[WingedOx]

(I'm scared of confrontation is the real problem I think)

As long as you're in an inpatient role, being conflict averse is NOT going to serve you well. I don't see this as conflict though. This is a responsibility of leadership.

If you really feel stuck, at least talk with your chief. He/she can be a big help for you in managing this type of thing. The'll want to know about your concerns even if he/she tells you it's your responsibility to fix.

 

[VenusinFurs]

I was pretty regularly seeing at least 7-8 by this point last year and if I was given 6 I'd be ready to do an admission by 3 in the afternoon, even if I wasn't familiar with those 6 patients. I think this is very much an example of not being given enough to do earlier/ maybe they had less inpatient than my class did because of scheduling dickery.

It's fine, I think I've got it.

 

[IlDestriero]

As noted above, your program is set up backwards. The medical student is the one that gets 2-3 patients, if you had any. The 1st years get the rest and the senior residents have the med students patients and supervise everyone else. The chief is the acting attending and has none of his own, or they are all theirs depending on how you look at it.
You coddle your interns and are then surprised they suck?
Fix your program.

 

[colbgw02]

Where are the PD and service attending in all of this? Is this just your current service, or is this systemic? If it's the latter then WTF? I know everyone is telling you to fix it, but if this is program-wide then it goes beyond your responsibility. Besides, senior FP residents don't typically have the same authority as a surgical chief does.

 

[DoctwoB]

Where are the PD and service attending in all of this? Is this just your current service, or is this systemic? If it's the latter then WTF? I know everyone is telling you to fix it, but if this is program-wide then it goes beyond your responsibility. Besides, senior FP residents don't typically have the same authority as a surgical chief does.

Part of the problem is the structure with an intern, a 2nd year, and a 3rd year. With 18 patients there should be 2 interns with 9 patients each and a senior supervising.

While I've managed up to 40 patients as an intern (double that in nights), remember that medicine interns cap at 10 patients by acgme rules (not sure if true for family med) and take a much more detailed approach. I would probably have the intern take 10 of the easier ones, the resident take the rest/sickest while supervising med student patients, and the chief as the acting attending. I agree with the above though that coddling the intern isn't doing them any favors. The only way to learn to manage a heavy census, write notes efficiently, prioritize problems, etc. is to actually do it. Youre cutting their legs out from under them.

 

[Member 1337]

(I'm scared of confrontation is the real problem I think)

As long as you're in an inpatient role, being conflict averse is NOT going to serve you well. I don't see this as conflict though. This is a responsibility of leadership.

Part of the PGY3 learning curve is working out how to be an effective leader in your own style. It's tough moving from a mindset where being a workhorse directly caring for patients needs to shift to teaching others how to care for their patients well. You're still working hard, but it's actively coaching and mentoring others how to care for their patients and manage their service.

Juniors will constantly try to pass their problems/monkeys on to you. Soon, you'll have dozens of little monkeys crawling on your back, distracting you from the gorillas, the really sick patients or unexpected medical urgencies that need prioritization and your involvement. HBR's "Who's Got the Monkey?" https://hbr.org/1999/11/management-time-whos-got-the-monkey is a great article that gives a run down on how juniors are adept at making seniors work for them and gives good coaching on how to avoid comon pitfalls.

 

[Perrotfish]

Part of the problem is the structure with an intern, a 2nd year, and a 3rd year. With 18 patients there should be 2 interns with 9 patients each and a senior supervising.

While I've managed up to 40 patients as an intern (double that in nights), remember that medicine interns cap at 10 patients by acgme rules (not sure if true for family med) and take a much more detailed approach. I would probably have the intern take 10 of the easier ones, the resident take the rest/sickest while supervising med student patients, and the chief as the acting attending. I agree with the above though that coddling the intern isn't doing them any favors. The only way to learn to manage a heavy census, write notes efficiently, prioritize problems, etc. is to actually do it. Youre cutting their legs out from under them.

I've worked in hospitals with both systems: the 4 man team with a second year and the three man team with just two Interns and a senior. I personally like the system with the second year much more. I have no idea why people think that Medical students who are used to handling 2-4 patients will suddenly be able to handle 10 because someone handed them a diploma. A good Intern year should be designed like a weight training program: you add a little more weight every month. That's how our clinic works (the appointment times get shorter ever few months during Intern year) and that's how the best wards I have rotated on work.

While I have seen Interns handed 10 patients on the first day of Intern year, I've never seen it done well, and usually it results in a combination of poor medical care, extreme work hour violations, and most of all seniors/attendings doing Intern work to prevent medical errors and work hour violation. There is very little teaching and I think the Interns actually mature more slowly because they spend so much time drowning in systems issues and fighting sleep deprivation that they never learn anything. Handing new Interns 10 patients is like telling a new lifter just to try bench pressing 400 lbs until he's able to do it.

 

[Perrotfish]

My second years just aren't where they should be. Their decisions are ok, but they seem to struggle with more than 6 patients and they've been asking me to pick up one or two of theirs. I have absolutely no problem with this, but if this is all they can do when they get to second year, we are ****ed. My co-second year residents have observed this is a problem with most of the first year class- they are either really slow or so haphazard that they miss big things.

Questions:

1) How big is your program? How many residents in each class?

2) I'm unclear who is struggling with 6 patients. You say 'my second years are struggling' and then say 'if this all they can do when they get to second year'. Are you saying that the Interns who are about to hit second year are struggling with 8 patients, or that the second year residents who are about to hit third year are struggling?

3) Are your observations corroborated by any other data? Does the class you're worried about have low inservice scores? Have there been higher rates of medical errors with this class? Are the attendings also concerned?

4) Is it just a handful or core sucky people you're worried about or do you think almost every person in the class is weak?

5) Has anything changed in your program between your class and this one? New rotation schedule? Added/removed rotation sites? New/different schedule for the year?

 

[Raryn]

... really? This must be a medical thing. I went from being a MS4 with 2 patients in May, to seeing 27 patients my first day of internship. I started at 2:30am and just barely finished in time for rounds at 0630 with the Chief.

Interns are the workhorse of the hospital. They should see almost everyone, and do almost all of the floor work. That's how we learn. When seniors are doing intern work, they're not learning how to be an attending, and the whole system starts to break down.

I saw 8-10 patients my first ward month as an intern. (10 being the cap as an IM intern)

That said, there's a lot more close supervision/handholding/double checking when you're seeing 10 in July compared to 10 in June. As a senior resident now, I am there primarily for oversight and consultation, but I don't always have to check to make sure that the potassium was supplemented or the orders put in. I'm also no longer there till late making sure everyone was wrapped up appropriately. In July on the other hand? My job was pretty different.

 

[WingedOx]

... really? This must be a medical thing. I went from being a MS4 with 2 patients in May, to seeing 27 patients my first day of internship. I started at 2:30am and just barely finished in time for rounds at 0630 with the Chief.

Interns are the workhorse of the hospital. They should see almost everyone, and do almost all of the floor work. That's how we learn. When seniors are doing intern work, they're not learning how to be an attending, and the whole system starts to break down.

well that, and I'm assuming y'all need to be in the OR while your interns are doing the scut. Medicine doesn't have that issue.

/psych is a whole different world about this.

 

[Perrotfish]

... really? This must be a medical thing. I went from being a MS4 with 2 patients in May, to seeing 27 patients my first day of internship. I started at 2:30am and just barely finished in time for rounds at 0630 with the Chief.

Interns are the workhorse of the hospital. They should see almost everyone, and do almost all of the floor work. That's how we learn.

Interns maxing out at 10-12 patients is a medical thing. We just write a lot more crap in the notes: more than 12 and the limiting factor becomes the speed you can type. Otherwise, though, I don't think that its particularly a medical thing to ramp up slowly in Intern year vs. dropping the Interns into the deep end. Like I said I have rotated through wards where Interns in June were given 10-13 patients. I just disagree that getting 10 (or 27) patients dumped on you on day 1 is the best way to learn. I think that learning happens at its absolute fastest when you are pushing yourself just slightly beyond your previous limits, with just barely enough time to type the notes, enter orders, and frantically read summary recommendations from uptodate on your patients. You get faster as you start to know the management of more conditions and learn to organize your time. You should also be spending just enough time out of the hospital to do a twenty minute work out and sleep at least 7 hours.

When it goes beyond that, though, its not really learning anymore. When you're sleeping 4 hours a night because you need to show up at 02:30, and you're rounding so fast that you don't have the time to try and look up anything on patients you don't understand (which in June is probably all of them) then you're not learning. Then you're just a burnt out zombie, trying to learn medical care based entirely on recognizing your seniors' patterns and preferences. That how you get doctors who do things because 'this is the way we do things'. That's not good, and if that is the system you're going for then you don't need a residency for that.

 

[VenusinFurs]

Questions:

1) How big is your program? How many residents in each class?

2) I'm unclear who is struggling with 6 patients. You say 'my second years are struggling' and then say 'if this all they can do when they get to second year'. Are you saying that the Interns who are about to hit second year are struggling with 8 patients, or that the second year residents who are about to hit third year are struggling?

3) Are your observations corroborated by any other data? Does the class you're worried about have low inservice scores? Have there been higher rates of medical errors with this class? Are the attendings also concerned?

4) Is it just a handful or core sucky people you're worried about or do you think almost every person in the class is weak?

5) Has anything changed in your program between your class and this one? New rotation schedule? Added/removed rotation sites? New/different schedule for the year?

My program has 27 people right now, with 9 in each class. I meant to say "my first years are struggling," but I might have had some Anxiety Beer. There's really no hard data as far as I know. I don't have concerns with this class's intellectual abilities by any means. I haven't heard anything from the attendings, other than one of the interns telling me our current attending provided her with some tips to become a little more efficient. The only thing I have to go by is my own subjective observations and the fact that my fellow second years have also made these same observations. They mostly just think the interns are lazy. And the general consensus is that all but one or two of them are problematic. I have no idea what changed between this year and last, other than maybe this year's third years were lazier and they inculcated laziness? My class has more people who are willing to challenge themselves, is the feeling I get?

I dunno, I had to pass up a really interesting patient that the hospitalist service offered us on Wednesday and it made me mad.

 

[Raryn]

My program has 27 people right now, with 9 in each class. I meant to say "my first years are struggling," but I might have had some Anxiety Beer. There's really no hard data as far as I know. I don't have concerns with this class's intellectual abilities by any means. I haven't heard anything from the attendings, other than one of the interns telling me our current attending provided her with some tips to become a little more efficient. The only thing I have to go by is my own subjective observations and the fact that my fellow second years have also made these same observations. They mostly just think the interns are lazy. And the general consensus is that all but one or two of them are problematic. I have no idea what changed between this year and last, other than maybe this year's third years were lazier and they inculcated laziness? My class has more people who are willing to challenge themselves, is the feeling I get?

I dunno, I had to pass up a really interesting patient that the hospitalist service offered us on Wednesday and it made me mad.

Ask the third years what they said about your class this time last year.

 

[Perrotfish]

My program has 27 people right now, with 9 in each class. I meant to say "my first years are struggling," but I might have had some Anxiety Beer. There's really no hard data as far as I know. I don't have concerns with this class's intellectual abilities by any means. I haven't heard anything from the attendings, other than one of the interns telling me our current attending provided her with some tips to become a little more efficient. The only thing I have to go by is my own subjective observations and the fact that my fellow second years have also made these same observations. They mostly just think the interns are lazy. And the general consensus is that all but one or two of them are problematic. I have no idea what changed between this year and last, other than maybe this year's third years were lazier and they inculcated laziness? My class has more people who are willing to challenge themselves, is the feeling I get?

I dunno, I had to pass up a really interesting patient that the hospitalist service offered us on Wednesday and it made me mad.

Its tough to know, but I suspect you don't have a problem. First what I now see that you're describing now seems like a very reasonable progression: you have Interns who are able to handle 6 patients in June, and they're about to need to handle 8 patients in July. That's a very reasonable incremental increase in responsibility, and I'm sure they'll adapt. Also while a class of 9 isn't huge, it's large enough that I wouldn't expect random variation in applicant quality to completely change the quality of their class vs. yours, and you don't have any systems changes that should have affected the quality of the education you received. They're probably not particularly dumb or lazy.

Odds are your class looked the same way to the class above you at the end of Intern year. Don't worry about it.

 

[colbgw02]

Ask the third years what they said about your class this time last year.

Good call. That last post from the OP sounds a lot like the get-off-my-lawn phenomenon.

 

[22031 Alum]

Most of the complaining in my program about the lower classes seems to occur at the beginning of the year. By the end of the year everyone is feeling their role, and we all get along great. Concerns at the end of a year are actually something of a red flag.

My program was the same way! In July and August, it was always who's too slow, too disorganized, etc. By May, even maybe April, you started to hear "You're basically a [N+1]" said to those same people as they were given more responsibility.

 

[mdpre001]

what to do?

don't help your juniors EVER. push them to get better on their own.

WRONG. You do what's best for the PATIENT.

 

[Law2Doc]

WRONG. You do what's best for the PATIENT.

I think the answer is between these two extremes. The juniors should be handling the patients by this time of the year. ALL of them. All the scut, all the notes, all the presenting patients to attendings, etc. The seniors should know all the patients and be trouble shooting -- making sure things don't slip through the cracks, making sure his team looks good to the attending, jumping on any grenades and dealing with irate attendings to protect his juniors, etc. But It really should never be an option for a junior to farm work upstream. Thats shocking. There's a difference between pitching in to help out a junior who is struggling versus actually assume their work, and I think the OP is on the wrong side of this line.

As I recall, when I was an intern, by this time of year the issue wasn't that we were relying on the seniors to help us out but the other extreme -- not keeping them in the loop enough. In morning rounds they'd say "you know you are allowed to call us about this kind of stuff". And we'd more or less say "chill out, we got this". That's the dynamic OP needed to create.

 

[VenusinFurs]

In re: what some people have said, the third years I have directly asked about this have said my class was not too difficult to deal with at the end of first year.

I kinda realized one of the interns who rotated off the service last week was pretty ok, and now I am left with one intern who kind of carries her weight (she just came on) and the other one who is struggling with 6 patients. She discharged two patients this morning and then saw, like, I dunno, two or three more in the afternoon? I ended up discharging one of hers and seeing the other, in addition to carrying three patients of my own, discharging one of the patients of the intern who is ok but had to go to clinic before the final disposition was decided, and picking up another patient who was accidentally admitted to the hospitalist service but is actually our clinic patient? And, like, I'm still having to admit people in the afternoon? And turning away interesting cases? It kinda seems to me this one intern is the issue, so far.

I still don't know what to do differently. I did notice that at 4:30 PM she was checking her clinic desktop and answering phone calls from people, and typically if I had three discharges to do and three complicated patients to see I would not prioritize that over getting my hospital work done and I would not shunt it off to my senior and I'd keep working until I got things wrapped up. From my perspective the list is not at all excessive (we're at 13 now) and it shouldn't be such a struggle to get things done.

 

[VenusinFurs]

I guess one thing is she texted me at like 1 o clock to say she needed me to see some of her patients and I just said yes. I might be kind of enabling this slowness.

 

[calvnandhobbs68]

... really? This must be a medical thing. I went from being a MS4 with 2 patients in May, to seeing 27 patients my first day of internship. I started at 2:30am and just barely finished in time for rounds at 0630 with the Chief.

Interns are the workhorse of the hospital. They should see almost everyone, and do almost all of the floor work. That's how we learn. When seniors are doing intern work, they're not learning how to be an attending, and the whole system starts to break down.

Try taking 27 medicine H+Ps and typing 27 medicine notes vs ortho notes and you'll find out what the limiting factor is. It's an extremely common thing for medical services to cap at 10ish patients per intern. Are you just intentionally dense about the differences between medical and surgical services or just pretending to be?

 

[calvnandhobbs68]

Your junior texted you (not called)... at 1am... to say she needed you to see her patients (didn't ask, just basically told you)... and you said yes.

I'm having a stroke right now.

Either I'm going to have to stop reading this thread, or you're going to have PM me her cell phone number so I can yell at her.

Do agree with this though...wat? The fact that she feels like she can text you and tell you to do her work is just I don't even...

Offering to help when the interns are obviously barely treading water and having work forced on you by interns are way different things. The best seniors I ever saw knew how to take some pressure off the interns but I don't think I've ever seen an intern telling a senior something along the lines of "I'm not going to get this done so you're going to have to pick it up". It went more like "you're obviously going to grossly violate duty hours if you have to coordinate another discharge so let me help you out with this other one so we can get two things done at once".

 

[Raryn]

Try taking 27 medicine H+Ps and typing 27 medicine notes vs ortho notes and you'll find out what the limiting factor is. It's an extremely common thing for medical services to cap at 10ish patients per intern. Are you just intentionally dense about the differences between medical and surgical services or just pretending to be?

The ACGME sets absolute maximum caps for IM at 20 per resident and 10 per intern. Many programs set the cap less than that. I know of a few that set the cap at 14 per resident and 7 per intern. (There's a ton of caveats that apply depending on how many are new/old/transfers/consults, but those are the numbers overall)

 

[Perrotfish]

Do agree with this though...wat? The fact that she feels like she can text you and tell you to do her work is just I don't even...

Your junior texted you (not called)... at 1am... to say she needed you to see her patients (didn't ask, just basically told you)... and you said yes.
.

I don't see an issue with this, assuming its not too common. I've been on both sides of this text. There's two of us there for a reason: if the Intern is getting pulled in 4 directions at once I think simple, direct text that help is needed is appropriate. That way I'll either say yes or I will do the Senior thing and triage.

Scenarios I personally don't want:

1) I don't want the Intern do be drowning and not call anyone. When patients sit in the ED for four hours unseen the ED attending doesn't call me, he goes over my head and sends nasty emails directly to my attendings. Ditto simmering nursing issues, un-acted upon critical lab values, and admitted patients without orders. Just tell me before its a problem.

2) I don't want the Intern to call me when they're drowning and then dance around it. This happens more often than scenario 1. If we're already behind as a team I really, really don't want you to call me, sign out everything that's happening on your list, and then wait for me to figure out that its not doable by one person and offer to help. Now we've wasted 10 more minutes. "I'm overwhelmed, could you please admit the patient in 5" is a perfectly reasonable thing to say.

Of course ideally as a Senior these phone calls never happen, because as a senior I should know my Intern is 3 patients behind before I need to get a phone call. But if it happens I think the best way for it to happen is a simple text or call.

 

[Siggy]

Yes, because your teams are doing 27 H&Ps in a morning.

You equate a short note with a short eval because you don't know any better. You ignore the fact that our notes are finished before you can even make your first complaint of the day about duty hours. You pretend like caps for medicine don't exist I order to justify what is fundamentally laziness by the OPs junior residents and interns. Yes, medicine notes are long, which is why they're not typically finalized until late afternoon; good thing they don't have anything else scheduled during the day.

Intentionally dense? Grab a mirror.

Finalized until late afternoon? Lulz. If I didn't have my notes finished prior to rounding (on up to 10 patients), then I'd be in a world of hurt. I wish I could finish notes after rounding because that would have been sweet.

 

[calvnandhobbs68]

Yes, because your teams are doing 27 H&Ps in a morning.

You equate a short note with a short eval because you don't know any better. You ignore the fact that our notes are finished before you can even make your first complaint of the day about duty hours. You pretend like caps for medicine don't exist I order to justify what is fundamentally laziness by the OPs junior residents and interns. Yes, medicine notes are long, which is why they're not typically finalized until late afternoon; good thing they don't have anything else scheduled during the day.

Intentionally dense? Grab a mirror.

Right right because as usual you work harder than everyone else in the hospital 🙄

You seem to have this obsession with trying to prove to everyone how hard ortho works. If it's so self evident, it should speak for itself instead of you having to come in and brag about how you carried 27 patients your first night intern year.

 

[calvnandhobbs68]

It's weird that you feel the need to personalize issues in a discussion about things you're not familiar with, and a situation you haven't encountered yet. Maybe someday you'll get some context that let's you speak a little more intelligently about these issues.

Eh to me it looks like you were the one talking about how you carried 27 patients your first night intern year and saw all of them before 6:30 (which is pretty much irrelevant to OP's situation in an entirely different residency program in an entirely different field). But that's just how I'm reading it.

 

[Siggy]

You seem to have this obsession with trying to prove to everyone how hard ortho works. If it's so self evident, it should speak for itself instead of you having to come in and brag about how you carried 27 patients your first night intern year.

Oh, we're talking about medicine vs Ortho? Lulz, there's a reason for the acronym, FOOBA... found on ortho, barely alive. It's easy to round on 27 patients if you can't even manage simple things like diabetes.

 

[Raryn]

It's hard to see how any of your scenarios apply at 1am, which is at least 3-4 hours before people actually start rounding.

And I would expect the courtesy of a verbal explanation of the issues (so I can determine what help is actually needed, rather than just accepting the dictated plan of an intern).

And I would expect to be respected enough to be asked for help, rather than told what I am going to be doing.

Reading that post, I don't see anything about 1am. I interpreted it as the intern asking for help at 1pm because they had a lot of work going into the afternoon.

 

[Raryn]

From the OPs subsequent post:



I took this to mean 1am, because why would a patient still need to be seen at 1pm?

From the prior post:

I kinda realized one of the interns who rotated off the service last week was pretty ok, and now I am left with one intern who kind of carries her weight (she just came on) and the other one who is struggling with 6 patients. She discharged two patients this morning and then saw, like, I dunno, two or three more in the afternoon? I ended up discharging one of hers and seeing the other, in addition to carrying three patients of my own, discharging one of the patients of the intern who is ok but had to go to clinic before the final disposition was decided, and picking up another patient who was accidentally admitted to the hospitalist service but is actually our clinic patient? And, like, I'm still having to admit people in the afternoon? And turning away interesting cases? It kinda seems to me this one intern is the issue, so far.

So for whatever reason, their workflow includes seeing patients in the afternoon. Whether new patients or they split the list up in some weird way, who knows. It's also consistent with the story about the other intern going to clinic (which usually happens in the afternoon). In that context, getting a text to see the patient at 1 o'clock is likely 1pm. The chance that the same intern is there in the afternoon and is awake at 1am (much less working) is pretty low.

 

[Siggy]

- FOOBA? Cute. We call you "assassins" and refer to the Medicine floor as the "Death Star." I guess every specialty has their fun little terms.

Sick patients sometimes dies. Not every thing can be solved by ancef and an ORIF.

 

[Siggy]

I guess as long as you're documenting their preferred communication method and whether they have pets at home, you've done all you can do.

To be fair, sometimes pets are important causes of disease.
http://wwwnc.cdc.gov/eid/article/9/11/03-0143_article

 

[VenusinFurs]

I dunno man. There's really no reason to not see 6 patients before 1 pm. Even if you spend half an hour with each one talking about how they like their nails did and etc. We have electronic notes, so you can really just type them up from one convenient location after seeing a bunch of patients. There are few excuses.

(Also umm the interns mention dvt ppx on each and every one of their notes but they still have patients on it inappropriately, like dudes with gi bleeds get left on lovenox)

Today was especially bad because the hospital's been on diversion and we've been under pressure to discharge a bunch of dudes, so I just did things for my one really slow intern so I wouldn't keep getting called by the pencil pusher doc. And then the case managers saw me as the lady clearly in charge so they kept asking me WHEN WILL THIS THING BE DONE and WHEN CAN THAT THING BE DONE. I'm just getting dumped on left and right here.

New policy: I will do what I can to keep people from dying, but my interns stay until they see and write notes on all their assigned patients. Because to be frank, these ****ers are all getting home before 8 pm and aren't even close to violating duty hours. And it's all because I'm too nice and afraid of confrontation to just tell my dudes to suck it up and see their dudes.

 

[VenusinFurs]

@Tired I don't think anyone's claiming that family medicine residency is as hard as ortho residency or that there isn't a lot of it that's hokey as ****, like this is p well known. And I say this as a person who willingly went into family medicine. Like I coulda done IM or physiatry or something.

 

[Siggy]

And occasionally an ORIF is helpful.

Yea... I didn't say they weren't helpful. I said that they aren't always the solution.

 

[rokshana]

I guess as long as you're documenting their preferred communication method and whether they have pets at home, you've done all you can do.

generally i see your point, but dude you need to chill...your attendings don't bill based on the particular content of your note... so your notes don't have to be detailed...heck they rarely have a complete sentence...and you can bill a level 3 with a focused exam...that is not they way medicine notes have to be written to get the higher billing...trust me if i could write just want was truly important i would...the work is the same but if the note is written one way i bill a level 3, another a level 1...10 IM notes is a lot more work than 27 notes in ortho...you look at one thing and one thing only ...that is rarely the case in medicine.

and you get the luxury of focusing on one area and can ignore the rest(yeah may be YOU can manage htn, dm, etc...but most of your brethren....not so much...and most IM peeps aren't even going to think they can do a splint or an I&D or all those things surgery does...

 

[Siggy]

The point I'm making is that the OP's juniors are clearly failing at their jobs.

Oh, I completely agree with that. At my hospital, it doesn't matter if you're an IM intern or an off service intern. You're expected to be able to see and write 10 patients worth of notes prior to morning report and implement the orders discussed during rounds and follow up as needed starting day one. The interns might not be nailing the plan day one (that's what residency is for), but unless you're literally discharging 10 patients to nursing homes, no one is going to shed a tear if you can't get your work done.

I keep mentioning the surgical world because that is my frame of reference, not to make some point that surgery is better than medicine. Maybe I just inspire ire from the Medicine people, or maybe not, but I'm amazed at how many people in this thread keep jumping the defense of these interns when what they are doing is very clearly inappropriate, lazy, and not up the standard expected of a physician.

The problem is that you're trying to compare 10 IM patients to 20+ ortho patients and it's not the same. At my hospital, the med students write the gen surg notes and they're cosigned by the intern, senior, and attending (with an addendum box for the senior and the attending on the preformed progress note). Heck, depending on the number of medications, I can spend a decent amount of time just transcribing those on a full load of medicine patients (we don't have electronic notes). There's also a difference in round, and by connection preround, complexity.

Are ortho surgeries more complex than any medicine procedure? YES.

Are medicine patients more complex when it comes to rounding than ortho patients? Yes (and, at my hospital, we have 2 dump teams for the pure placement/long term IV ABx patients, so those tend to leave teams quickly and get refilled when on call or by redistribution patients).

What it boils down to is trying to compare surgery vs medicine ward work is more than a bit apples to oranges.

The intern can't manage to carry more than a handful of patients. Can't manage to see six people before 1pm (sorry about the 1am vs 1pm confusion). Treats the senior like an assistant ("You're gonna need to see some of my people"). This isn't an issue of "we're a team" or "the intern is getting pulled in four different directions" or whatever name people are slapping on it. This is a substandard intern who is going to be a substandard resident.

I have to wonder... is this a community hospital? Because I can't think of a traditional teaching team taking to 1pm to start rounding on a regular basis. (full disclosure, I've started rounding at 1pm before... and it was because I was post night float... so I had 10 patients and the earliest I was "allowed" to show up was 11am since it was a 24 hour "day off." This is also a known an allotted for situation).

Consider that this person, in two years, will be in independent practice. What kind of cap does an attending hospitalist have? Who do they call to see their patients for them? Apparently this person is incapable of seeing more than one inpatient an hour. How's that going to work for her in a couple years?

In a word? Badly. The hosptialist non-teaching teams at my hospital doesn't have a cap.

 

[Perrotfish]

Consider that this person, in two years, will be in independent practice. What kind of cap does an attending hospitalist have? Who do they call to see their patients for them? Apparently this person is incapable of seeing more than one inpatient an hour. How's that going to work for her in a couple years?.

I took what he wrote to mean that the Intern started her day with 6, discharged three, and then picked up 2-3 more in the early afternoon. She then got behind on her notes and asked for help with one of the discharges and one of the H&Ps.

Tough to tell how bad that is without knowing what's on the service, and how complicated the admits and discharges were. H&Ps or discharges for healthy patients with asthma or cellulitis should take a June Intern no more than 30 minutes each. H&Ps for massively comorbid patients with a weak command of English unclear etiologies for their complaints? Verifying their medications alone can take 30+ minutes.

Don't get me wrong, this could be a weak Intern. They do exist. The only thing that makes me suspect it's not, actually, a weak Intern is the fact that the OP started this thread by saying that he has a weak Intern class. Not one Intern, 9 Interns, and they're all weak. That could happen as well, but it would be a lot weirder.

 

[Shikima]

Unfamiliarity breeds inefficiency.

 

[gutonc]

One point though: we absolutely do bill based on note elements, just like everyone else. That's why our initial consult notes tend to be quite long. Post-op though, everything is bundled under the global code, so less important.

I think this is something that the vast majority of non-surgeons (in training or practice) don't understand. I know that I didn't get it either until I was on the BMT service where an admission for stem cell transplant is also under a global code so gets paid a certain amount, regardless of how much/little documentation happens (within reason of course).

 

[IlDestriero]

I think this is something that the vast majority of non-surgeons (in training or practice) don't understand. I know that I didn't get it either until I was on the BMT service where an admission for stem cell transplant is also under a global code so gets paid a certain amount, regardless of how much/little documentation happens (within reason of course).

"Doing well.
AVSS.
No ."

 

[Raryn]

Not tracking on this change. Are we moving away from bundled services?

Yes. CMS is tired of paying surgeons a global fee that assumes they'll do their own post-operative care only to have the surgeon turf it to a hospitalist who bills separately.

 

[Raryn]

Interesting. Wonder how many hospitalists lose their job over this.

I'd say it's more likely the surgeons just take a pay cut (or increase case volume) rather than go back to doing their own busywork.

 

[dozitgetchahi]

My program has 27 people right now, with 9 in each class. I meant to say "my first years are struggling," but I might have had some Anxiety Beer. There's really no hard data as far as I know. I don't have concerns with this class's intellectual abilities by any means. I haven't heard anything from the attendings, other than one of the interns telling me our current attending provided her with some tips to become a little more efficient. The only thing I have to go by is my own subjective observations and the fact that my fellow second years have also made these same observations. They mostly just think the interns are lazy. And the general consensus is that all but one or two of them are problematic. I have no idea what changed between this year and last, other than maybe this year's third years were lazier and they inculcated laziness? My class has more people who are willing to challenge themselves, is the feeling I get?

I dunno, I had to pass up a really interesting patient that the hospitalist service offered us on Wednesday and it made me mad.

For starters, the format of your teams is bizarre - in IM, you have 2 interns seeing up to 10 pts and a 2nd/3rd year resident who maybe has the sub-i's patients. There is no mixing of 1st/2nd/3rd years on the same team, and the chief as essentially an 'executive' who has no direct involvement on individual teams unless something weird happens (intern falls unconscious on a shift, etc). Interns see all their pts and there is no 'hey can you take my pts' etc. You put up or shut up, and interns who can't get it together have their feet held to the fire.

Is this structure more of an FM thing? One of our hospitals has FM teams rounding, and those teams tend to have 3-4 housestaff per team and yet are notorious for super disorganized and inefficient care. The nurses hate dealing with the FM teams. I wonder if all this isn't just a function of FM housestaff being less efficient/effective at inpatient care since they do less of it.