Does practicing medicine involve teamwork, individualism, or both?

[DermViser]

One of the quickest things I learned on night float was to NEVER trust the day interns if the attending or chief hasn't seen the patient yet.

"Oh, the guy in 7 is just here with a malfunctioning AV graft, I don't even know why he's admitted. Next patient..."

Walk in the room, patient is septic from pussed out graft. Delirious, no fluids fluids running, no abx.

That same intern did the same thing like 4 times last month where he signs out patients in unrecognized sepsis/septic shock whom he restarts on their home statin and that's it.

I started making sure I saw every patient in the unit myself when I came on for nights rather than just waiting for a nurse to give me a call when something went wrong. Learned to do that quick after some ***** intern was running KVO fluids on a septic patient, and he went into florid shock with anuric renal failure and MODS about 2 hours into my first or second shift.

I'm not some great genius or rockstar intern, but I've noticed some that just have zero ability to spot trouble and deal with it (and call the ******* senior).

All that being said, I've seen plenty of "veteran" NPs do equally stupid ****. That's why I think interns should be heavily supervised and NPs should be heavily supervised.

You're using an example of an intern who obviously didn't see the patient and signs things out badly? Really?

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[VisionaryTics]

You're using an example of an intern who obviously didn't see the patient and signs things out badly? Really?

1. He did see the patient, and 2. That's what bad interns do. He couldn't recognize a sick patient, gave a distorted picture of the patient to the senior over the phone when he called it in, and did a crappy signout because he had no real grasp of the clinical condition of many of his patients.

I've learned that "vague signout" = "I have no idea what's going on".

I don't really think he's lazy. In fact, I think he's usually scared ****less because he recognizes his deficits. Because of that, he'll improve over time as he develops his clinical acumen, but right now he just misses stuff a lot.

I mean, come on, you read what medical school is like for a lot of people on this board. It's basically shadowing, often at some crappy community hospital staffed by docs who couldn't recertify if their lives depended on it. It doesn't surprise me that when these med students start actually taking care of patients, they are lost and dangerous.

 

[KnuxNole]

Ladies and gentlemen: if you're curious why medicine has gone to hell in the last 2-3 decades, look no further. Hate to say it, but you sound like you're from the generation of doctors that has been asleep at the wheel for the last 30 years.

As of now, there's nothing we as a people can do about it. At least, I can't think of anything.

 

[KnuxNole]

Also, TONS of interns have really, really crappy signouts. Especially the first 6 months. That's the point though, they need to learn. Nobody really learns how to do that in medical school, so it's a new skill. As well as taking care of patients, a lot of interns for the first time are seeing sepsis and having to think of what to do for the first time in their lives, which is scary. Like Visionary mentioned, thousands of med students have no actual hands on training, which is highly expected. However, i think it's best to escalate everything to the senior instead of just assuming it's ok and leaving it. I know I probably called my senior over 200 times a day

 

[Mad Jack]

So would you rather be treated by an NP/PA or a PGY-1? You don't get to add any qualifiers like "experience level".

Freshly graduated? I'd go PA>NP>MS1. If it's something serious, every single one of them will likely kill me though lol.

 

[DermViser]

1. He did see the patient, and 2. That's what bad interns do. He couldn't recognize a sick patient, gave a distorted picture of the patient to the senior over the phone when he called it in, and did a crappy signout because he had no real grasp of the clinical condition of many of his patients.

I've learned that "vague signout" = "I have no idea what's going on".

I don't really think he's lazy. In fact, I think he's usually scared ****less because he recognizes his deficits. Because of that, he'll improve over time as he develops his clinical acumen, but right now he just misses stuff a lot.

I mean, come on, you read what medical school is like for a lot of people on this board. It's basically shadowing, often at some crappy community hospital staffed by docs who couldn't recertify if their lives depended on it. It doesn't surprise me that when these med students start actually taking care of patients, they are lost and dangerous.

Most allopathic medical schools use hospitals that are directly connected to the med school itself, often with the same name to identify themselves as affilated with the medical school.

 

[DermViser]

Also, TONS of interns have really, really crappy signouts. Especially the first 6 months. That's the point though, they need to learn. Nobody really learns how to do that in medical school, so it's a new skill. As well as taking care of patients, a lot of interns for the first time are seeing sepsis and having to think of what to do for the first time in their lives, which is scary. Like Visionary mentioned, thousands of med students have no actual hands on training, which is highly expected. However, i think it's best to escalate everything to the senior instead of just assuming it's ok and leaving it. I know I probably called my senior over 200 times a day

This works better in your specialty than others.

 

[Mad Jack]

All that being said, I've seen plenty of "veteran" NPs do equally stupid ****. That's why I think interns should be heavily supervised and NPs should be heavily supervised.

I agree completely.

My point isn't that PAs and NPs are great, just that MS1s are, well, not so much either. All of them need supervision, but the MS1 generally is going to need it the most.

 

[Mad Jack]

Most allopathic medical schools use hospitals that are directly connected to the med school itself, often with the same name to identify themselves as affilated with the medical school.

Even at the big hospitals, med students just do glorified shadowing and note taking, with maybe a question or two thrown their way during rounds. There's a whole lot of watching and practically no doing because of liability concerns.

 

[KnuxNole]

This works better in your specialty than others.

Shouldn't it work in surgery too? If the intern has a crashing septic patient, they should feel comfortable phoning/texting the upper level without fear. Unless the senior is a pathetic resident.

 

[pulmoblast]

It's funny how when things are going well it's all because of "teamwork", but when bad outcomes happen...the MD gets the court summons


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[KnuxNole]

It's funny how when things are going well it's all because of "teamwork", but when bad outcomes happen...the MD gets the court summons


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Having their cake and eating it too is just too much fun.

 

[DermViser]

It's funny how when things are going well it's all because of "teamwork", but when bad outcomes happen...the MD gets the court summons
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That's interprofessional "teamwork" for you.

 

[VisionaryTics]

Most allopathic medical schools use hospitals that are directly connected to the med school itself, often with the same name to identify themselves as affilated with the medical school.

The operative word is most, and many state medical schools with a ton of students (mine among them) also send students to community sites. Many students rank these community sites high in the clerkship lottery because they have a reputation for being cushy.

Also, I didn't want to start an MD/DO flame war, but this guy is a DO student so I'm assuming his clerkships were largely at community hospitals.

That being said, many community hospitals are excellent, with phenomenal teaching faculty who teach residents and med students regularly. For example, the community hospital where I did my general surgery clerkship was known for being the best operative and busiest clinical site for the general surgery residency program at my med school. The attendings were all faculty at my med school, and the program director operated there twice a week. The students who rotated there largely did so because they were going into general surgery or surgical specialties, and wanted the most demanding clerkship possible. On my two months, every single med student was junior AOA and matched into general surgery, ENT, or plastics.

I agree completely.

My point isn't that PAs and NPs are great, just that MS1s are, well, not so much either. All of them need supervision, but the MS1 generally is going to need it the most.

I think you mean PGY1.

Even at the big hospitals, med students just do glorified shadowing and note taking, with maybe a question or two thrown their way during rounds. There's a whole lot of watching and practically no doing because of liability concerns.

Agreed. To reference the above, the academic hospital general surgery service was terrible clinically; med students spent one week on each service, with no responsibility, and very little hands on time. They spent most of their time in the corner watching fellows and chiefs do transplant cases and crap like that.

Shouldn't it work in surgery too? If the intern has a crashing septic patient, they should feel comfortable phoning/texting the upper level without fear. Unless the senior is a pathetic resident.

Still takes the ability to recognize a sick patient, and then communicate the clinical situation to the senior. Often the senior is covering multiple pagers and dealing with other admits and consults on the floor or something.

If I want the senior to see the patient immediately, I will explicitly ask. Otherwise he will come down only after I have gathered up a few admits or procedures to be done or whatever. That could be a couple of hours or more.

 

[DermViser]

The operative word is most, and many state medical schools with a ton of students (mine among them) also send students to community sites. Many students rank these community sites high in the clerkship lottery because they have a reputation for being cushy.

Also, I didn't want to start an MD/DO flame war, but this guy is a DO student so I'm assuming his clerkships were largely at community hospitals.

That being said, many community hospitals are excellent, with phenomenal teaching faculty who teach residents and med students regularly. For example, the community hospital where I did my general surgery clerkship was known for being the best operative and busiest clinical site for the general surgery residency program at my med school. The attendings were all faculty at my med school, and the program director operated there twice a week. The students who rotated there largely did so because they were going into general surgery or surgical specialties, and wanted the most demanding clerkship possible. On my two months, every single med student was junior AOA and matched into general surgery, ENT, or plastics.

Then that explains his putrid performance - not bc he's a DO student, but bc he rotated at private community hospitals in which med students don't do much in terms of writing a note, coming up with your own differential and A/P, and presenting in a cohesive manner, staying for sign out, etc.

I guess they must be quite low-tier med schools then that don't have their own academic medical center hospital. Most allopathic medical schools do have their own academic medical center.

 

[KnuxNole]

True, however, I wouldn't expect the intern to know how to communicate it properly in the first few weeks...I mean,yes they will get the basics but they will still miss certain details, which is understandable when you are doing this for the first time. Hell, I wouldn't be surprised if a lot of new interns would NOT know what a sick patient looks like...especially if it's not textbook like. I dunno, I have a lot of leeway for new interns, especially since they are coming in with NO experience and zero hands on, actual experience.

 

[VisionaryTics]

I guess they must be quite low-tier med schools then that don't have their own academic medical center hospital. Most allopathic medical schools do have their own academic medical center.

Absolutely, but if you've got more than 150 students in a class, it's very common for at least some of those students to do core clerkships at a community site while some of the students are at the main academic medical center.

I went to a med school with one of the largest internal medicine programs in the country, but with 180 students in a class and 1/4 of those doing their medicine clerkship at once plus subIs and rotators, it's simply not realistic to expect every single student to be able to be at the academic center simultaneously.

The way it worked for us was 4 weeks inpatient general at VA or university hospital, 4 weeks outpatient general and subspecialty at either university/VA or community hospital, 4 weeks at community hospital.

 

[VisionaryTics]

Hell, I wouldn't be surprised if a lot of new interns would NOT know what a sick patient looks like...especially if it's not textbook like. I dunno, I have a lot of leeway for new interns, especially since they are coming in with NO experience and zero hands on, actual experience.

Exactly. And you can't rely on the ED or consulting service to properly triage patients either, so I think as a senior you have to have a high sphincter tone whenever interns are seeing patients without direct oversight. Example: I was ENT and we got called for two angioedemas at the same time. One was on the floor, and the consulting service intern was flipping a ****. I think the words I heard on the phone were "his face is actively swelling and on the verge of obstructing in front of me". At the same time, we got a call from the ED (one of the interns) who called in an angioedema consult saying she "had a little bit of lip swelling, and seemed OK, can you come see her". I don't know whether the intern had seen the patient with an attending or his senior yet, but that's the consult I got.

My senior and I split up, him going to the "sick" patient, and me going to the "stable" patient.

He walked in and saw a guy with cellulitis on his lower lip, and zero oral or oropharyngeal swelling. Airway wide open.

I walked in and saw a morbidly obese stridulous patient with a history of severe uncontrolled asthma with multiple intubations, a trach scar, severe facial swelling, tongue so big I could maybe see a couple of cm of the hard palate.

I mean you can have leeway for new interns, and I'm not sure what happened in either of these cases in terms of oversight, but come on this **** is terrifying

 

[KnuxNole]

It is terrifying, the ED example in particular. Even with some ED attendings, I get the occasional admit call for "Oh, he's a little short of breath, he looks like he needs to stay overnight, i'll send him up" and it results in needing to transfer to the unit and being put on a ventilator within hours.

 

[fab4fan]

Esp. when they say stuff like this:
http://observer.com/2009/12/the-nursecrusader-goes-to-washington/2/
For her part, Ms. Mundinger readily concedes that there are some things nurses are not educationally equipped to do: oncology, surgery, things that call for medical specialists. But she argues that, if anything, primary care physicians are overeducated. “I spoke to the Federation of State Medical Boards, the people who run all board certifications, and a primary care physician stood up and said, ‘Are you saying I wasted my time going to medical school?’” recalled Ms. Mundinger. “I wanted to say, yeah.”

She's an idiot.

 

[DermViser]

She's an idiot.

Yup. She is. She's the one who started the NP movement. Unfortunately, it's people like her who have the ears of policy makers to say just the right words to expand scope of practice for NPs to practice medicine...oh I'm sorry nursing, independently and autonomously. I feel most sadly for the elderly.

 

[DermViser]

It is terrifying, the ED example in particular. Even with some ED attendings, I get the occasional admit call for "Oh, he's a little short of breath, he looks like he needs to stay overnight, i'll send him up" and it results in needing to transfer to the unit and being put on a ventilator within hours.

They're EM. Not at all shocked.

 

[giantswing]

I feel like the scope of competency is far broader with nurses/nps than residents. Also i feel it's unfair to compare an intern or resident who is supervised and still learning, versus an NP who is supposed to be able to be independant (with out all those "un necessary" years of training.

 

[ImmunoLove]

As an incoming medical student, I was wondering what your experiences have been so far in medical school/residency. Do you find yourself working heavily in a team-work setting, or working as an individual making decisions on your own? I'm sure this is different for everyone, so I'd love to hear about your experiences.

without having read the responses: Both. And, it depends. Ha!

No really, it depends on what you're doing exactly. In either case, you will have to collaborate with colleagues of various specialties when taking care of a patient, however. And in that sense, there's always some teamwork. Most medical fields tend to rely on the team effort to provide the best care. So be independent, and play nice.