cupcake residency?

[sarcopenia]

Greetings,

It is interesting that in this healthcare reform debate, and in the comparison between MD's and "alternate PCP's" (e.g. NP's, PA's), the number of training hours gets mused about a lot.

One of you (sorry, I forget who) has a tagline comparing the number of hours for a DNP ~ 700, PA ~ 2000, and MD (FP presumably?) ~ 17,000.

I did a bit of mental math, and realized that with my current residency program (which is non-malignant to the point of being ridiculous, hence "cupcape residency), I may be more like a mid-level than a "real" doctor in terms of my training hours and environment.

1. Family medicine residency in my country (Canada) is only TWO years. I haven't looked it up, but I'm told this is the "shortest family medicine residency in the WORLD." Which is a bit scary, I guess...

2. At my particular training site, we residents are "non-essential." It is a community-based hospital, and we are sort of "just there." True, the more gung-ho of us are running codes and stuff, but some of us just seem to be hanging out at times. Because we are non-essential, the call schedule is arbitrarily set at q4 (as opposed to q-Resident). There is never more than 1 (or 2 at most) residents rotating through a given service at any one point of time.

3. In second year, because of the way my program is structured (mostly electives in second year, mostly core rotations in first year), there basically is NO call. This excludes "voluntary call" for people taking acute care electives in ICU, etc.

4. Protectionistic environment. There are certain learning opportunities, like IV courses, offered through various nursing departments. What boggles my mind is that we have to JUSTIFY why we need to know certain of these skills (e.g. proof of intent to work in a rural area post-grad, etc.). In my (unfortunately, usual) abrasive way, I made a statement to the gatekeepers that "all doctors completing a residency here should be entitled to these training opportunities." I think that slammed the door shut in my face.

With nothing (much) else to lose, I'll admit that I took it to the next step with something like, "Whether you choose to 'teach' me about IV access or not is irrelevant. A nurse does not certify the competency of a doctor. I have sufficient experience from electives to do IV's, and if a patient under my care (e.g. in the ER) needs an IV, and nursing doesn't step forward in a timely manner, I'm going to throw one in whether you like it or not."

5. Total hours? Probably 60 - 80 per week in year 1 and 40 - 60 per week in year 2 ... giving 3000 - 4000 in first year + 2000 - 3000 in second year or 5000 - 7000 total. According to the "training hours" paradigm, I'll be 1/2 (or even just 1/3) of the doctor that most of you are (going to be). And I'll admit, from some of your posts, you guys DO seem like superheroes at times.

6. Relative comparison. All of my evaluations have been good (well my Obs/Gyn comments were sort of "damning with faint praise" but numerically still checked out). If I had to guess, I think the attendings would consider me in the 75th %ile of the residents that they routinely see. However, I have a sense that my training centre might not attract the most hard-core or ambitious residents. It could be that we are a select (? mediocre) group, and that it is easier to float to the top in such an environment.

Also, some of the attendings are less than stellar. Recently, I was working in a long-term care setting and I was mumbling to myself / half-asking the attending (who happened to be sitting nearby) about ? QT prolongation on an EKG I was reading. The automatically calculated interval was within limits, but it looked to me like the machine was being fooled by abnormal T-wave morphology. The attending was like "QT prolongation? I don't know much about that. I'd have to get out my old Dubin [basic EKG text used for EMTs, nurses, med students] and check it out."

***

Any comments / advice? I'm not about to consider switching residencies as I have < 1 year remaining, I'm doing well here, and well, I'm lazy. The only thing I could think of to assuage my concerns is that I can't be the only person in this boat. Also, NP's and PA's don't seem to have infiltrated the Great White North to the same degree as in the US, so maybe I can use the first few years in practice to sharpen up before I'm "found out." Don't worry, I'm sure I'll (along with most recent grads) have a lower threshold for ordering tests and making referrals for the first year or two.

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[deleted87716]

I think you need to train for a minimum of three years. I'm not alone.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2668992

If you have the option to take an additional year, I suggest you do so.

 

[thethom]

NPs and PAs don't have to do residency, Id imagine the number of training hours is how much they trained in school. Add college, med school, and residency and you are looking at ~12 years after high school to become an MD, hence the 17,000 hour number quoted before. You must train for 6 years after high school to become a PA, and 2 total years to become a nurse, not sure sbout DNPs but I know its nowhere near PA or MD training. Don't worry about PA's and NPs taking over and making more, remember they are generally employed by MDs so if we make less, they will make less. Unless there are some major changes in state by state law, mid levels will never be able to practice independently...

Also I don't think your residency is representative of the majority of US FM residencies. The idea of an IV course is preposterous to me, ok maybe for a med student but not a resident. That being said, you went to college, medical school, and residency, which means you put wayyyy more into it than any other level of practitioner...

 

[lowbudget]

Interesting. I thought FM was 3 years in Canada or at least people have to do 1 internship year before starting a 2 year program, but maybe I was wrong.

1. Just there- You're a grown person. No one's going to spoon feed you or hold your hand to learn something. They'd rather you go away than to bother them. If you're interested in doing something or learning something, find out what you can do to help out with the daily work. Clean toilets if you have to. Earn your respect, and people will start teaching you things. If you waltz in somewhere and tell them that you are entitled to training opportunity, you will have doors slammed. If that had been my junior resident or med student, I would've slammed the door in your face, open it, and slam it again.

2. Time- The actual time spent in training doesn't on-face matter. You can spend 5 years sitting on the couch in the resident's lounge and still not learn a damn thing during residency. The question is: How well are you spending your time. Family medicine in a 3 year program, where you rotate through services, and may see smattering of patients through continuity clinic is short enough. You need to make the most of your time as possible. Being there for 3 years gives you 1 more year of opportunities. But you have to seize the opportunities and make opportunities reality for you. With a 2 year program, you need to work harder (not less) than someone in a 3 year program.

3. Culture- I tell med students this all the time that culture matters. Unfortunately, you go to a program where maybe past residents ruined the learning opportunities for you and so now you carry a bad reputation deservingly or not. And you can't escape it. Make the best of the opportunities you have and create opportunities for yourself. Maybe you'll earn the respect of the hospital staff. Maybe you'll be the one to be the agent of change.

4. All is not lost- You still have <1 year to fill in the gaps. The fact that you admit that you're lazy is telltale to me however. Just remember that in the real world, Darwin principles rule and the weak don't survive. They get picked off from the herd, and just being a doctor won't protect you if you suck. So, if you're worried about midlevels (like Blue Dog said) you probably should be. But like I said, all is not lost... you have time to reinvent yourself.

Or not, I don't care.

 

[sarcopenia]

Interesting (and for the most part, useful) responses.

Unfortunately, I do not have the option to apply for a 3rd year program at this time, due to contractual obligations.

Re: my response to the nursing provided course (and please note, this isn't just to "teach" us about IV access, to but to get some kind of "stamp of approval" from the nurses, hence the inherent tension), I already admitted that my approach may not have been the most productive. I will say in my defence that I was initially more tentative and exploratory in my questions before the door was slammed. I also had a bit of an advocacy role, and was voicing the thoughts of several of my (indignant) peers. Not excusing my actions, just explaining them.

Re: "getting out there and doing things," "seizing the day" or other such sentiments, we (all residents in my program) are obviously cognizant of this (such thoughts are present throughout the culture of medicine). Sometimes that approach works, but often it doesn't. When making the call schedules, certain preceptors are selected (or not selected) based on their willingness to teach. Some of the attendings will literally "hide out" and/or not page the residents when things are happening, simply because they can't be bothered to have "an underling." You can only emphasize your interest and availability so much before it becomes annoying.

Case in point, there were some ultra-keen medical students during my clerkship who volunteered to hang out with the residents even after being (repeatedly, officially) dismissed at 1700 or 1800. This one girl was still there until like midnight, and was literally following the residents around, almost walking into the male bathroom by accident at one point. I overheard a conversation the next day (more like I was present, but ignored for the purposes of the conversation), wherein the 2 residents she was following were talking about ways to get rid of her, etc.