Division of labor

[the fat man]

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Hey guys, none of you probably remember me but I wrote a couple posts long long ago, way back before internship began. I think back then my biggest worry was as a prelim intern, would I be treated worse than my fellow categoricals? The answer turned out to be yes, for a varied number of reasons. Main one being that we are spread far too thin in three separate hospitals with way too many medicine services--and ICUs in particular--apparently putting categoricals at risk of violating the RRC rules which regulate how many ICU and night float months a resident may do over a 3-year residency. Thereby making prelims fill in the extra months that need warm bodies, leading to the vicious cycle of it being a bad place to be a prelim, leading to the prelim spots not filling the next year, leading to the prelims who are there getting more unit and night float rotations,...

I guess the thing that frustrates me most about my program besides being assigned a much tougher schedule than many of the other interns (extra unit time, more night float, more holidays on call) is the way they designate day to day responsibilities among different members of the team. I don't know if we have any official policy dividing up intern vs. resident tasks, but on most services the interns do basically all the actual work from soup to nuts--write the admission H&P, get outside records, put in all orders, preround and collect vitals, call specialty consults and update family members, solve any interdisciplinary issues (with case management, social work, PT, etc.), pester nurses to get things done, do the discharge teaching, write the discharge scripts (and at one of the hospitals, occasionally pick up the meds from the pharmacy and HAND-DELIVER them to the patient's room), literally play secretary and call all the primary care and specialty clinics to schedule follow-up appointments for the patients, and finally, dictate the discharge summary within a day of discharge. The resident is the "supervisor" training to be an attending, meaning they briefly see the patients at admission, go over the basic plan with the intern, make lists of all tasks that need to be done by the interns, and generally back us up if we're unsure about how to manage a patient. On night float, interns do all cross-cover (25-50 patients, depending on the hospital) and all admission workups, with the resident once again providing basic supervision if we need advice on what to do. On a typical night float shift, for example, it is not uncommon for the intern not to sit down once other than perhaps to enter orders, while residents frequently get to read, check email, study for boards, etc.

On a side note, interns have 10-11+ service rotations (very little elective time because as above there aren't enough interns to allow people to spend much time off-service) while upper-level residents may have as few as 5-6 over the course of a year. So not only is any single month much tougher for an intern, there are also way more of those months. Long story short, being an intern at my program, especially a prelim, is downright brutal.

Where I went to med school, certainly the interns were expected to carry much of the daily workload. However, when the service got especially busy the residents were instructed to go as far as take on a couple of the patients as their primary patients, effectively serving as an res-intern on those patients so that the intern wasn't overwhelmed. At one hospital where I rotated all discharge summaries were dictated by the resident; interns didn't even get access to the dictation service. On night float furthermore, the duties of cross-cover and admissions were often completely divided, where the intern would only have to cross-cover or only have to admit, while the other task would go to the resident.

So my question for y'all...what's normal where you are? Perhaps I don't have it as bad as I thought, perhaps my med school's hospitals were just much more protective of the interns than most. Before you label me a disgruntled complainer, let me say that the program has been surprisingly supportive and willing to listen to us. They try to make the program educational, and have fought to add non-teaching services. However, the hospital itself either can't or won't spend the money to provide adequate relief such as more non-teaching services, or PAs/NPs to help with the load. The non-teaching services even have gotten the power to hand-pick their admissions, taking only the easy chest pain rule-outs and turfing the homeless drug addict who comes to the ED to get their Dilaudid fix and then somehow is allowed to stay for 3 days getting IV pain meds while refusing to let anybody even take vitals.

 

[Droopy Snoopy]

Hey guys, none of you probably remember me but I wrote a couple posts long long ago, way back before internship began. I think back then my biggest worry was as a prelim intern, would I be treated worse than my fellow categoricals? The answer turned out to be yes, for a varied number of reasons. Main one being that we are spread far too thin in three separate hospitals with way too many medicine services--and ICUs in particular--apparently putting categoricals at risk of violating the RRC rules which regulate how many ICU and night float months a resident may do over a 3-year residency. Thereby making prelims fill in the extra months that need warm bodies, leading to the vicious cycle of it being a bad place to be a prelim, leading to the prelim spots not filling the next year, leading to the prelims who are there getting more unit and night float rotations,...

I guess the thing that frustrates me most about my program besides being assigned a much tougher schedule than many of the other interns (extra unit time, more night float, more holidays on call) is the way they designate day to day responsibilities among different members of the team. I don't know if we have any official policy dividing up intern vs. resident tasks, but on most services the interns do basically all the actual work from soup to nuts--write the admission H&P, get outside records, put in all orders, preround and collect vitals, call specialty consults and update family members, solve any interdisciplinary issues (with case management, social work, PT, etc.), pester nurses to get things done, do the discharge teaching, write the discharge scripts (and at one of the hospitals, occasionally pick up the meds from the pharmacy and HAND-DELIVER them to the patient's room), literally play secretary and call all the primary care and specialty clinics to schedule follow-up appointments for the patients, and finally, dictate the discharge summary within a day of discharge. The resident is the "supervisor" training to be an attending, meaning they briefly see the patients at admission, go over the basic plan with the intern, make lists of all tasks that need to be done by the interns, and generally back us up if we're unsure about how to manage a patient. On night float, interns do all cross-cover (25-50 patients, depending on the hospital) and all admission workups, with the resident once again providing basic supervision if we need advice on what to do. On a typical night float shift, for example, it is not uncommon for the intern not to sit down once other than perhaps to enter orders, while residents frequently get to read, check email, study for boards, etc.

On a side note, interns have 10-11+ service rotations (very little elective time because as above there aren't enough interns to allow people to spend much time off-service) while upper-level residents may have as few as 5-6 over the course of a year. So not only is any single month much tougher for an intern, there are also way more of those months. Long story short, being an intern at my program, especially a prelim, is downright brutal.

Where I went to med school, certainly the interns were expected to carry much of the daily workload. However, when the service got especially busy the residents were instructed to go as far as take on a couple of the patients as their primary patients, effectively serving as an res-intern on those patients so that the intern wasn't overwhelmed. At one hospital where I rotated all discharge summaries were dictated by the resident; interns didn't even get access to the dictation service. On night float furthermore, the duties of cross-cover and admissions were often completely divided, where the intern would only have to cross-cover or only have to admit, while the other task would go to the resident.

So my question for y'all...what's normal where you are? Perhaps I don't have it as bad as I thought, perhaps my med school's hospitals were just much more protective of the interns than most. Before you label me a disgruntled complainer, let me say that the program has been surprisingly supportive and willing to listen to us. They try to make the program educational, and have fought to add non-teaching services. However, the hospital itself either can't or won't spend the money to provide adequate relief such as more non-teaching services, or PAs/NPs to help with the load. The non-teaching services even have gotten the power to hand-pick their admissions, taking only the easy chest pain rule-outs and turfing the homeless drug addict who comes to the ED to get their Dilaudid fix and then somehow is allowed to stay for 3 days getting IV pain meds while refusing to let anybody even take vitals.

The different treatment compared to categoricals sucks, no doubt about it. I may have missed it but how many extra unit months are you talking about? 3 months or less seems to be the norm from my experience (I had two, 1 MICU and 1 CCU). All that stuff I bolded really doesn't sound out of line to me, with the exception of hand-delivering meds from the pharmacy -- that's crazy. This time of year though you should be able to do carry 8-9 medicine ward patients in this manner without a problem. Yeah your resident should be pitching in calling consults instead of checking their email, but it sounds absolutely reasonable for them to be reading up on the literature and supervising you plan instead of dictating summaries (seriously, that's an intern's job, or med student's even). As far as crosscover goes, I've got surgical intern friends with 3x your nightfloat load, not that that's ideal just saying it could be worse. It does sound like there could be better division on the night float service. Question on that though; if night float does all the crosscover and admits all the patients, what does the call team do?

Anyway so yeah it sounds like you're in a lower-end program who is using prelims for a little cheap labor. It'd be nice if some things were changed and you had some extra elective time. But in general I didn't hear anything that's abusive per se, against established rules, or significantly outside the norm of what we've all been doing for the last umptyf*ck years. Being an intern blows, bottom line. Vent a little sure, but try to roll with it and just do the best you can to get through the year.

 

[dragonfly99]

I often didn't have time to sit down, pee or even really to eat on call nights when I was an intern. I would say that is normal at a tougher internship program, and not just at "lower end" hospitals. I would also say that this type of internship is getting less and less common. It does sound like you did med school at one of the places that was more protective of interns, so I can see why all this would surprise you.

Dictating discharge summaries can be either the intern or the resident's job. At my program, the cooler residents would do some or most of them, but the weren't required to. The sucky ones would "delegate" everything to the interns...LOL.

The other stuff all sounds like stuff I did when I was an intern, except the delivering meds from the pharmacy. We also had to make phone calls to get the patient a f/u appointment - I actually think this is important - interns don't do this at my current hospital and many patients get lost to followup.

As an intern I had zero elective months (and I was a categorical), 1 clinic month, 2 ICU months and the rest all medicine wards. We did not have night float, but all ward months were Q4 overnight 30 hour calls, and all ICU months were Q3 30 hour overnight calls. The on call interns did all the admissions and all the crosscover, and the on call ICU intern wrote the daily notes for all the patients on the service for the next day. Unfortunately only the cushy programs (i.e. ones that don't really rely on house staff to make the hospital run in terms of taking the lion's share of the admissions, or ones that just have a lot of house staff) have elective months for interns.

I do think it is very sucky of your program to give prelims a lot worse schedule than categoricals. It ruins morale and it's just...well...unfair. Assuming you are going on to do some other specialty (radiology, anesthesia, etc.) I would just roll with it and not complain too much. This may be the crappiest year of your life, but you will get through it. If you're doing anesthesiology, the extra ICU months may turn out to be a blessing in disguise, because having too FEW ICU months as an intern would be a bad thing for you. If you are going on to do something like derm or rads, then you're not going to get much benefit out of a bunch of ICU months...

You're just at one of the harder medicine internships, probably. You won't change it by dwelling on it, though, so I'd advise just slogging through. People don't really want to hear what hte problems are - they probably know but the hospital isn't willing to spend the money to fix the problems that are causing your overwork.

Cross covering 45-50+ medicine patients at night is just painful...I commonly crosscover 10 or 12 cardiology patients on call at night as a fellow but that is NOTHING to crosscovering your average IM patient. Patients who just come in for procedures, etc. or just have 1 or 2 things wrong with them are a far cry from elderly IM patients or a bunch of crazy drug users. This is part of why surgery interns can crosscover 60 patients or something...half of them are there for appies, lap chole, etc. Not that their internships don't suck worse than IM ones, but it's for other reasons...

 

[Winged Scapula]

The OP's experience sounds painful but not out of the realm of normalcy for any residency.

Many programs have few to no elective months (even non-surgical ones), interns and junior residents do dictate the discharge summaries (we did not allow medical students to do them) and all the work the OP has listed are common intern level duties. It would be nice if the work was more evenly divided but this is not uncommon and shouldn't be used as a measure of program quality.

Yes, surgical residents can and do cross cover more patients at night, but IMHO most of those *aren't* appys or lap choles (which, in the latter case, as an elective case, are outpatient) because those aren't typically done at academic medical centers/tertiary care hospitals. YMMV of course, but our volume was high because of trauma, bariatrics and peds not bread and butter surgery cases. Sounds like DF trained at a different type of program (I could do a Whipple before I felt comfortable doing an appy, that's how few we did).

I *would* rather have more surgical patients than your typical IM patient any day.

At any rate, you've been given some good advice by DF - its 1 year, which sucks for most of us. I suspect that your medical school, like many, did not prepare you for the possibility that things will be different out there in the "real world" (which begs the question, "does coddling medical students really do them any good?").

 

[atsai3]

Sounds not unlike my intern year experience--well, except for the hand-delivering the meds part.

In my program they also treated the prelims like dirt in subtle ways. For example, the notorious "day float" rotation was staffed mostly by prelims.

-AT.

 

[kappa1]

My program's intern year is exactly like yours, except we didn't actually pick up the meds from pharmacy for home. Seniors are there to help with plans or sick kids, but not to take on extra pts or pre-round.

Your medical school program sounds very cush, and perhaps much smaller?

 

[Law2Doc]

The OP's experience sounds painful but not out of the realm of normalcy for any residency.
...

Agreed. The tasks are certainly not out of line with what interns are doing at most hospitals. I even did the pharmacy run once or twice to ensure that someone got off of my service when I decided to give them the boot a few minutes before the pharmacy closed. Every day isn't reasonable, but a once or twice thing isn't a big deal. But in terms of prerounding, H&P and dictation paperwork, pestering nurses/consults to make sure things happen -- that's what interns do everywhere, whether the place is benign or malignant.

The difference in treatment of prelims and categoricals is less blatant at most places, but it's pretty hard for attendings or the program to "invest in" folks who are only going to be around for a year to the same degree. You see the little differences even if it's just an attending deciding that a given intern is going to be around long enough to merit putting their name into his cell phone, or something silly like that.

As far as having worse schedules, a lot of us didn't have (m)any electives and did a ton of cross covering/call/ICU months, so I don't know how much sympathy you are going to get. Most of what you describe is what internship is all about -- it's right out of the brochure. A lot of what you seem to think residents should be doing in lieu of interns is simply not the way it works at the majority of programs.

 

[Buzz Me]

I often didn't have time to sit down, pee or even really to eat on call nights when I was an intern.

I still have calls like that, even as a senior resident. It doesn't always end after your PGY-1 year.

 

[dragonfly99]

I agree, but if you are a medicine resident it usually does get a bit better as the senior resident, at least on most rotations, and particularly when you are PGY3 since you're doing the same stuff you did during PGY2, but with a year more experience. Being an upper level surgical resident I am sure doesn't necessarily get easier. Being PGY2 IM can be a bit scary the first few months and/or during IC months, but it definitely doesn't suck as much on wards as it did being the intern, mostly because of the lack of crosscover.

With the new work hours limits for interns next year, expect more upper level residents being a "resitern" covering for the interns more and doing more H and P's, crosscover and discharge summaries. At least that is my prediction.

 

[Top Gun]

What you're doing now really doesn't sound out of the norm for most interns (except for hand-delivering meds). I mean, sure, intern year sucks, but it doesn't sound like your program is treating its interns any differently than most other programs. Do you write the admission orders too? At my program, the senior residents do that. We also write the discharge summaries, go to the interdisciplinary rounds and sort out the discharge issues with case management/social work, and, for at least the first 6 months, seniors call the consults. But I think my program is probably a little bit easier on the interns than most ones. I was an intern at another program before it closed due to the hospital filing bankruptcy, and over there, as interns, we did pretty much everything, including calling consults, doing discharge summaries, and going to the interdisciplinary rounds. Also, it was pretty much useless to pester the nurses over there to draw blood. Most of the time, they would say they couldn't get it, and we would have to draw it ourselves. When I moved to the program I'm in now (this was in March of my intern year), things were a lot easier for the interns.
Anyway, the point is that intern year pretty much sucks everywhere. Prelims, however, may get treated worse in some ways, such as getting extra call nights.

 

[Dr.LeoSpaceman]

In line with what everyone else is saying, your intern year doesn't sound too far out of the range of normal. I do all the stuff you mention, save for the pharmacy runs and discharge teaching. I have zero elective months, and on NF/call I'm often covering 50-75 patients plus consults/admissions or traumas. On night float, there isn't a senior for in-house. It's tiring, but fun too.

As for the division of labor between residents/interns, I think it's resident dependent. In my opinion, a good senior will set an example for the whole team, helping out when things need to get done and they don't have other things to do. At our program, they aren't "required" to do "intern work", but the vast majority of them will if things are crazy. That's why I like the program, though--the culture of it is very collegial and team-focused. If you're sitting around surfing the 'net while the rest of the team is getting slammed, it's going to be frowned upon, regardless of what training level you are.

 

[Luv2Cut]

I know that intern life sucks. But thats just how it is. The truth is you can't learn to be a doctor unless you are admitting and managing pts.

If it seems unequitable at times then you are the one actually getting more experience and exposure. You are going to get stretched in your intern year to do alot of things you haven't done before. That's good. At the end of your intern year you will be more than ready for R2. Do you really want to look back one day and say you had a cushy internship?

WS brings up an interesting point. IMHO codding med students and for that matter coddling interns doesn't do them any good. It may make you the popular senior resident that likes to help the interns and make their life easy but in the end it doesn't help you. I think it's good for the senior or the attending to pitch in when the service is really getting slammed. But ultimately the intern needs to learn how to manage alot of things going on at once. At my institution the intern managed the ED hits, the floor, the unit, OB triage and L&D. So they may have a pt to admit, check on an ICU pt., take calls from the floor, have a pt. in labor that needs a note every two hours and may get an OB pt. in triage for workup.

It is very hard as an intern to see the big picture here when you are sleepy, hungry, haven't seen your family or SO in days and all you care about is the next time you can sleep and essentially "do nothing." So try not to be bitter and just plow through and do what you need to do. In the end you'll be a better doctor for it.