Feedback on 4+1 vs trad clinic schedule

[shiftingmirage]

There's a thread about which programs offer 4+1, or similar, but I didn't see a thread about opinions of 4+1. Do you like it, dislike it, indifferent? At the program I IVed at, they are starting it in 2014, so I couldn't really ask the residents.

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[bombas238]

I always thought being in a 4+1 program would be important to me, but I ended up ranking a program under the traditional system as my #1 (for many other reasons). I have Monday morning clinic and I honestly don't think it's a big deal at all -- by the time I get back to the hospital most of the heavy work is done. When my team co-intern has clinic, I return the favor. People with PM clinic just peace out afterward and that's fine as well.

There are no talks about switching to 4+1 or 3+1 because nobody has even brought up concerns/complaints with the status quo.

 

[235009]

At this point I can't imagine surviving residency without a +1 system.

Pros:
- You know when your golden weekends are
- you get a golden weekend every 4-5 weeks
- you get to focus on clinic during clinic week and it's not just a nuisance
- a week of being a real adult with a real job working 8-5
- cut down on handoffs while on wards (not having to cover cointern's patients)
- you can't have more than 3-4 brutal weeks in a row

Cons:
- can't schedule someone for quick (ex 2 wk) f/u in clinic
- work with the same group of interns throughout the yr

So basically 3+1 or 4+1 is crucial for mental health. Also forces you to take clinic seriously and learn outpatient medicine better. Sometimes after my clinic week I'm shocked we actually are getting paid to do it as I typically work <40 hrs that week! Also at my program we work with residents from a program that has the traditional schedule and I heard nothing but complaints about it. At the time my countern had 4 weeks of the ward rotation we were on followed by 4 wks of MICU! It's unfathomable.

 

[NewYorkDoctors]

I am at a 4+1

You dont always get a golden weekend every 5 weeks with us since we do not have 24 hour call. A night float system is in place and often we have to give the main night floaters a night off over our golden weekends.

As for quick follow up, they can always come back, just to see another resident. Usually we just leave very detailed notes for those cases and give very specific instructions for what to do based on labs/imaging.

All in all it's not bad. On floors without the clinic schedule interfering, I have more time to do some academic reading... as well as to entertain families of patients...

 

[medbeewedme]

(Bumping this 4-year-old thread instead of starting a new one!)

Curious if there's any residents whose program switched from traditional to X+Y while they were in it... and how you feel having experienced both?

Any other opinions on X+Y vs Traditional from people who have interviewed at both?

 

[ilovecorgis]

Any other opinions on X+Y vs Traditional from people who have interviewed at both?

Interviewee here. There are tradeoffs of both systems. I prefer X+Y because the separation between continuity clinic and wards fits much better with my learning style, and having to run to clinic after rounding sounds awful. Most new systems are arranged such that you rotate with a predetermined set of residents on your X+Y schedule, so finding people to hang out with during afternoons off is more straightforward since you know exactly which residents also are on clinic at the time. This lets the program have a smaller feel, which I prefer. Having a golden weekend semi-regularly is also clutch.

That said, I’m starting to realize that an important downside of X+Y is that since program coordinators need to schedule whole separate weeks of continuity clinic, you (on average) get less time for electives. Hence, traditional schedules might give you more flexibility in subspecialty exploration. Some residents I met actually expressed preference for a mixed inpatient/outpatient day because they argue many attendings in the real world have to handle both simultaneously, which may or may not be of importance to you and your goals.

Ultimately, I prefer X+Y, but its just one factor among many in forming my rank list. Whatever I match into, I’ll adapt.

 

[InvestingDoc]

My program switched from traditional to 4+ 1 when I entered into my third year of residency.

The biggest 2 factors for the 4+1 schedule were that I had regular clinics that made follow up with my patients easy and I knew when I would get a golden weekend.

The traditional system did not allow me to prepare for weekend trips ahead of time since call schedules were done month to month. It was very hard to make plans to get away when I had no idea if I would be on call when I was scheduled to be on clinic. I went more than 5 months in a row my intern year without a golden weekend as a result of the traditional schedule. The 4 + 1 schedule gave me a golden weekend every weekend after my plus one and it was amazing. It made scheduling much much easier.

I wouldn't have minded a traditional schedule if I would have more of a work life balance and not going half a year without a golden weekend. If a program can build this into their system I think the traditional system can not be all that terrible. However, the 4 + 1 is better for providers, scheduling, and I would argue patient care.

There is a reason why very few hospitalist also have their own clinics. No one wants to have a full hospital panel list and do a half of a day of clinic on top of that. It's exhausting.

 

[HoldTheCoffee]

I trained in a "traditional" program. There were definitely times when it was painful to have clinic and be on inpatient at the same day - in that setting I could see how a 4+1 or 3+1 system might be easier schedule-wise. That being said, I really liked my IM program and overall enjoyed my time in residency. I personally don't think I'd pick a residency program solely based on how the outpatient clinic scheduling works, but that's just me

 

[CatFactorial]

I used to think it matters but it doesn’t. Clinic sucks regardless of structure.

 

[cbrons]

I’m a categorial at a 4+1 program.

I think residency would be terrible with anything else. I get golden weekends every clinic week which is usually a 40 hour week or almost always less and it really helps prevent/minimize burnout.

 

[IMreshopeful]

I trained in a traditional residency structure with afternoon continuity clinics. We had zero clinics during icu months and a lot more elective time than we would have had in a 4+1 system. I have no regrets. It was not the inhumane torture that people were making it out to be and served as a reasonable break from floors.

Almost all IM fellowships have the same structure of weekly clinics so those folks who don’t enjoy the idea are in for a huge shock. For me it was nbd.

 

[DoubleBogey]

I trained in a 6+2 model - those 2wks elective (inpt or outpt) and clinic were glorious.

 

[868853]

I’m a categorial at a 4+1 program.

I think residency would be terrible with anything else. I get golden weekends every clinic week which is usually a 40 hour week or almost always less and it really helps prevent/minimize burnout.

This. True of all X+Y programs.

Clinic block = magic

 

[NurWollen]

I'm a peds resident but I also hate going from the inpatient floor to clinic. Everything piles up.
My question is, is X+Y possible in a smaller program? Is there a certain number of residents needed to make that kind of a schedule work?

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[GastriqueGraffin]

X + Y is a lot better (especially when on ICU call) but should not be a deal breaker for a program you otherwise like.

 

[DoubleBogey]

Hated being a senior with a med/peds resident who had to cut out in the afternoon for clinic - resi-tern’ing more than I liked.

Agree with the above, non x + y programs shouldn’t be r/o because of lack block style scheduling...but block scheduling is much better for resident health IMO

 

[gutonc]

I trained in a traditional residency structure with afternoon continuity clinics. We had zero clinics during icu months and a lot more elective time than we would have had in a 4+1 system. I have no regrets. It was not the inhumane torture that people were making it out to be and served as a reasonable break from floors.

Almost all IM fellowships have the same structure of weekly clinics so those folks who don’t enjoy the idea are in for a huge shock. For me it was nbd.

I also trained in a similar system (no clinic on ICU months, afternoon clinic on a specific day, all work signed out to co-intern/resident or senior by lunch time and no going back to the floor after). It worked fine. I actually think it made clinic worse for me though.

The program is now X+Y (I think 4+1 but don't actually know, or really care) and it seems to work just fine still.

 

[Rhandhali]

I'm in a 4+2 system. It's awful. A third of my training is just just totally wasted in clinic.

 

[yaledoc]

I prefer traditional. When that easy month comes along, you get multiple weekends off. Also gives more time to work on research and follow up on clinic stuff before heading back to wards. Don't forget the importance of immersive elective time. When I had clinic during ward months, I would just go home after clinic - our team would take care of it.

Another thing I forgot to mention. Basically any attending physician on service has clinic from time to time. That is not going to change. Might as well get used to managing both.

 

[IMreshopeful]

The above two posts describe exactly how I feel about this whole deal. I liked having more elective time and less continuous time in primary care clinic.

 

[DoubleBogey]

I like primary care and loved it, certainly I can see if you’re inpt/speciality driven it could suck. Today I rounded at 4am, saw my my clinic pts in the AM (half day) and then did some nursing home admissions - no program can prepare you for actual practice, but you got train where you’re most comfortable. Good luck

 

[Rhandhali]

The above two posts describe exactly how I feel about this whole deal. I liked having more elective time and less continuous time in primary care clinic.

That's why I'm a big believer in the primary care track. If you want to do primary that's cool. Definitely not my thing but I imaging eating two months of ICU every year isn't what the primary care people want to do. Two weeks of clinic at a time for me is two weeks of hell; I end up depressed and miserable and I feel like I'm worn down and soft when it comes time to get back to inpatient. I'd rather give up the regular golden weekends and eat the inconvenience of having my day interrupted for 6 hours for continuity clinic. Requirements for IM are a half day of continuity clinic a week and that is more than I want.

We operate on a 4+2 system. Two weeks straight clinic with weekends unless you are on backup or shifted over to nights which happens. The morning is given over to "specialty" clinics which means standing around in the hallway for four and a half hours of a 5 hour clinic block looking at my phone during my third turn in the wound care clinic watching someone else put unna boots on. It means showing up to orthopedics or urology and immediately being asked what the hell I'm doing there. Or getting screamed at by some random attending when you show up at 7:55 for the 8:00 start time your chief told you when the clinic actually starts at at 7 which is followed by administration throwing you under the bus and punishing you somehow.

The downtime is nice, sure, but I could be doing a thousand other things up to and including just playing video games in a drunken stupor that are more useful than what most of my clinic experience has been.

And it's not true about attendings having clinic every so often. Some places you do pure outpatient or pure inpatient; that is certainly the case where I'm at. None of the hospital medicine people ever do clinic that I know of and none of our clinic people ever do inpatient to the best of my knowledge. It's different everywhere; a lot of places still make you round in the AM and do clinic in the afternoon. I have no idea what it's like but I know I'd hate it.

 

[IMreshopeful]

I like primary care and loved it, certainly I can see if you’re inpt/speciality driven it could suck. Today I rounded at 4am, saw my my clinic pts in the AM (half day) and then did some nursing home admissions - no program can prepare you for actual practice, but you got train where you’re most comfortable. Good luck

That sounds like my personal hell. Rounding in SNFs etc on dementia, incontinence, and UTI...

To each their own

 

[DoubleBogey]

That sounds like my personal hell. Rounding in SNFs etc on dementia, incontinence, and UTI...

To each their own

It’s not hell if you like it - it’s not work really. I’ve done my time placing emergent leukophresis lines for blast crisis, multiple pts crumping on you in the middle night without backup, difficult to ventilate pts trying advance ventilator management strategies, starting ecmo, transvenous pacing, IABP and impellas - I fine with sending that out and someone else having at it day in and day out. I’ll take my mix of medicine in outpt and inpt, with the so called “mundane” chief complaints and comorbidities...to each their own

 

[IMreshopeful]

It’s not hell if you like it - it’s not work really. I’ve done my time placing emergent leukophresis lines for blast crisis, multiple pts crumping on you in the middle night without backup, difficult to ventilate pts trying advance ventilator management strategies, starting ecmo, transvenous pacing, IABP and impellas - I fine with sending that out and someone else having at it day in and day out. I’ll take my mix of medicine in outpt and inpt, with the so called “mundane” chief complaints and comorbidities...to each their own

You were placing IABPs, Impellas, and cannulating for ECMO as a resident? Or you mean you just called the interventional guy on call?

I’ve done all of the other things too. I’m not a fan of everything which is why I would never be a lifelong resident or a hospitalist. I am just glad someone likes doing the mundane stuff in all honesty. We need more people like that

 

[grt398]

...I can see if you’re inpt/speciality driven it could suck....

I think this is kind of the crux of the matter as I feel like with the development of the hospitalist career path there are more IM residents who have limited interest in outpatient medicine. I've certainly come across applicants this year who straight up said as much. My class seems to have a pretty good mix of people who are interested in outpatient specialities like rheum/endo/geriatrics etc (and a smaller number of primary care focused people) and those who would prefer to spend the majority, if not all of their time, doing inpatient.

 

[GastriqueGraffin]

Unless you are purely CCM or a hospitalist, at least 1/2 your work will be outpatient. Every program should have residents go to subspecialty clinics to get a real flavor for the field and not just see inpatient consults.

 

[epicandprivate]

I can tell you, having worked at least a year in both 3+1 and traditional style that I would definitely factor this into rank list decision if I had to do it all over again. X+Y is the way to go. My program transitioned after my intern year. The traditional clinic model is a mess. You have to complete a full days of work in a half day and run to clinic in the afternoon and juggle both IP and OP work. It's miserable. After switching to the 3+1 model in my program I noticed a huge difference. It's nice to be dedicated to one setting. Mind you, I hate clinic and the 3+1 means more clinic for me but still worth it. The pros at my program we also get to pick 2-3 half day of subspecialty clinic in our Y. The other huge positive to X+Y is you know your yearly schedule from the start of the year. You'll know every golden weekend you'll have which makes planning trips easier. Only downside I would say is I noticed that making changes to schedule is much more difficult from an administrative stand point which can make things less flexible. Just my two cents.

 

[Rhandhali]

Oh I forgot the worst thing about X+Y schedules. You are still responsible for all of your outpatient stuff. Doesn't matter what you're doing. The outpatient staff haven't been in the same building as a sick person in ten years or more on average but to them not sending a letter about a patient's normal results (no we don't have people to do that for us) is the worst offense imaginable.

I go from two weeks of clinic dealing with bull**** and then I move to the ICU for a month or 5 weeks or whatever doing 100+ hours a week with a list in the 40s, bouncing between days and nights every four or five days. If I miss something, it doesn't matter what, by 12 hours, taking time away from actual sick patients, I will get phone calls and angry emails.

X+Y means more clinic time which means more not sick clinic patients which means more bull**** to deal with. Absolutely not worth it.

 

[GastriqueGraffin]

Oh I forgot the worst thing about X+Y schedules. You are still responsible for all of your outpatient stuff. Doesn't matter what you're doing. The outpatient staff haven't been in the same building as a sick person in ten years or more on average but to them not sending a letter about a patient's normal results (no we don't have people to do that for us) is the worst offense imaginable.

I go from two weeks of clinic dealing with bull**** and then I move to the ICU for a month or 5 weeks or whatever doing 100+ hours a week with a list in the 40s, bouncing between days and nights every four or five days. If I miss something, it doesn't matter what, by 12 hours, taking time away from actual sick patients, I will get phone calls and angry emails.

X+Y means more clinic time which means more not sick clinic patients which means more bull**** to deal with. Absolutely not worth it.

Sounds like your ICU sucks and 2 weeks of clinic would be a welcomed relief. But I agree that 2 week clinic is a bit much. A 4+1 is probably best. Also depending on where you practice, inpatient BS like dispo stays is often just as bad or worse as any outpatient paperwork BS.

 

[DoubleBogey]

Oh I forgot the worst thing about X+Y schedules. You are still responsible for all of your outpatient stuff. Doesn't matter what you're doing. The outpatient staff haven't been in the same building as a sick person in ten years or more on average but to them not sending a letter about a patient's normal results (no we don't have people to do that for us) is the worst offense imaginable.

I go from two weeks of clinic dealing with bull**** and then I move to the ICU for a month or 5 weeks or whatever doing 100+ hours a week with a list in the 40s, bouncing between days and nights every four or five days. If I miss something, it doesn't matter what, by 12 hours, taking time away from actual sick patients, I will get phone calls and angry emails.

X+Y means more clinic time which means more not sick clinic patients which means more bull**** to deal with. Absolutely not worth it.

Set your inbox to “out of office” - if your program makes you respond/follow up on results from the outpt setting then shame on your program. We always set our inbox out-of-office when on ICU, out of program rotations (VA, hospitalist rotation at community hospital etc) or vacation. Sounds like you just don’t like outpt

 

[Rhandhali]

Sounds like your ICU sucks and 2 weeks of clinic would be a welcomed relief. But I agree that 2 week clinic is a bit much. A 4+1 is probably best. Also depending on where you practice, inpatient BS like dispo stays is often just as bad or worse as any outpatient paperwork BS.

Set your inbox to “out of office” - if your program makes you respond/follow up on results from the outpt setting then shame on your program. We always set our inbox out-of-office when on ICU, out of program rotations (VA, hospitalist rotation at community hospital etc) or vacation. Sounds like you just don’t like outpt

Not an option that's available to us for Reasons. We have people that are allegedly covering for us but the system just doesn't work and isn't really looked after or enforced so it all comes down to us. We're specifically told that we are responsible for our clinic patients no matter what, but as I said that's a dictum that comes from the only primary care person that's involved in administration who has no idea what we actually do when we're not in clinic.

Honestly dispo doesn't bother me. It did at one point, but I realized that dispo issues are totally beyond my control. There is literally nothing I can do about not being able to safely discharge people when they don't have insurance or have property keeping them from going on medicare which keeps them from finding a nursing home that will accept them (nursing home's gotta get paid) or when they are a methadone maintenance patient on medicaid and the only nursing home that will take them cant or won't continue methadone maintenance. Can't fix it, no reason to worry about it and just accept it as an easy progress note and move on to the people with issues I can fix.

When it hits the extremes, say 2 or 3 weeks or more, hospital admin is good about moving those patients to a staff team. It's only so that they can make sure that the teams scheduled to admit on a given day are able to admit enough patients without hitting their caps early but whatever.

And I do absolutely loathe outpatient. I'm totally fine living on the edge of drowning for weeks at a time in the ICU but switch me over to clinic... I get bored and depressed and miserable. I never wanted anything to do with it when I applied for residency, but I wasn't good enough to do anything else so I got stuck in internal medicine where upwards of a third of my training is just pissed away in clinic.

Thankfully I'll be able to do pure critical care after I finish fellowship. Yes, I'll be pulm boarded but I don't ever actually plan on using and the clinic schedule is much, much more limited where I'll be doing fellowship.

 

[GastriqueGraffin]

Not an option that's available to us for Reasons. We have people that are allegedly covering for us but the system just doesn't work and isn't really looked after or enforced so it all comes down to us. We're specifically told that we are responsible for our clinic patients no matter what, but as I said that's a dictum that comes from the only primary care person that's involved in administration who has no idea what we actually do when we're not in clinic.

Honestly dispo doesn't bother me. It did at one point, but I realized that dispo issues are totally beyond my control. There is literally nothing I can do about not being able to safely discharge people when they don't have insurance or have property keeping them from going on medicare which keeps them from finding a nursing home that will accept them (nursing home's gotta get paid) or when they are a methadone maintenance patient on medicaid and the only nursing home that will take them cant or won't continue methadone maintenance. Can't fix it, no reason to worry about it and just accept it as an easy progress note and move on to the people with issues I can fix.

When it hits the extremes, say 2 or 3 weeks or more, hospital admin is good about moving those patients to a staff team. It's only so that they can make sure that the teams scheduled to admit on a given day are able to admit enough patients without hitting their caps early but whatever.

And I do absolutely loathe outpatient. I'm totally fine living on the edge of drowning for weeks at a time in the ICU but switch me over to clinic... I get bored and depressed and miserable. I never wanted anything to do with it when I applied for residency, but I wasn't good enough to do anything else so I got stuck in internal medicine where upwards of a third of my training is just pissed away in clinic.

Thankfully I'll be able to do pure critical care after I finish fellowship. Yes, I'll be pulm boarded but I don't ever actually plan on using and the clinic schedule is much, much more limited where I'll be doing fellowship.

You basically answered this thread with this one post. If you want to do pure hospitalist/CC then dedicated clinic week(s) will be hard to appreciate. For most everyone else I think clinic week, if run well, separate of inpatient duties, is the way to go.

 

[Raryn]

(Bumping this 4-year-old thread instead of starting a new one!)

Curious if there's any residents whose program switched from traditional to X+Y while they were in it... and how you feel having experienced both?

Any other opinions on X+Y vs Traditional from people who have interviewed at both?

My program did tradition for all interns and X+Y (something like a 4+2+2 with wards+clinic+elective, but vacation and nights threw the pattern off, regardless it was clinic weeks) for PGY2+3. They both have pluses and minuses, but I preferred the X+Y. Easier to compartmentalize things and not have to worry about one responsibility while you were off doing another.

I'm in a 4+2 system. It's awful. A third of my training is just just totally wasted in clinic.

One third of your training is required to be outpatient regardless (counting primary care, outpatient electives, and EM as outpatient). It's an accreditation requirement for IM. You're not in hospitalist residency.

 

[rokshana]

One third of your training is required to be outpatient regardless (counting primary care, outpatient electives, and EM as outpatient). It's an accreditation requirement for IM. You're not in hospitalist residency.

Which probably would be a good idea to have...inpatient and outpatient medicine is so different

 

[GastriqueGraffin]

Which probably would be a good idea to have...inpatient and outpatient medicine is so different

No they're not. The pace and acuity are different but not the medicine. There's a very big problem with residents being very dependent on specialists because their knowledge sucks. If you need to consult to diagnose and treat gout as a hospitalist or know how manage DM or what pneumonia needs inpatient vs outpatient and how, then you are going to be part of the problem of American medicine.

 

[rokshana]

No they're not. The pace and acuity are different but not the medicine. There's a very big problem with residents being very dependent on specialists because their knowledge sucks. If you need to consult to diagnose and treat gout as a hospitalist or know how manage DM or what pneumonia needs inpatient vs outpatient and how, then you are going to be part of the problem of American medicine.

I am a specialist now but was Hospitalist for a while between residency and fellowship. I’m quite comfortable dealing with the acutely sick but frankly have no idea how to deal with the health Maintance aspect of outpt care anymore...and I’m sure that those who have been practicing outpt medicine only would be a bit nervous dealing with the hospitalized pt...they are becoming 2 different arena...heck even the Abim has a different tract for hospital medicine now

 

[GastriqueGraffin]

I am a specialist now but was Hospitalist for a while between residency and fellowship. I’m quite comfortable dealing with the acutely sick but frankly have no idea how do deal with the health Maintance aspect of outpt care...and I’m sure that those who have been practicing outpt medicine only would be. Bit nervous dealing with the hospitalized pt...they are becoming 2 different arena...heck even the Abim has a different tract for hospital medicine now

By that logic, medicine subspecialties should be residencies of their own without medicine. I doubt any of the specialists who only practice their field know anything about anything else. I may sooner buy that than a generalist who doesn't know about general medicine problems.

 

[rokshana]

By that logic, medicine subspecialties should be residencies of their own without medicine. I doubt any of the specialists who only practice their field know anything about anything else. I may sooner buy that than a generalist who doesn't know about general medicine problems.

And frankly that may make sense. After all at some point you didn’t have to do a fellowship to be a cardiologist or pulmonologist...the evolution in medicine may be hospital medicine and primary care medicine...

 

[GastriqueGraffin]

And frankly that may make sense. After all at some point you didn’t have to do a fellowship to be a cardiologist or pulmonologist...the evolution in medicine may be hospital medicine and primary care medicine...

Medicine is dead the day outpatient internist doesn't know how to recognize and treat an NSTEMI or hospitalist doesn't know how to read a dexa scan report. I can tell that I won't change your mind and you are not the only one and maybe you're right that it's already at that point. I went into medical school to be a doctor but maybe I'm old fashioned.

 

[Raryn]

Medicine is dead the day outpatient internist doesn't know how to recognize and treat an NSTEMI or hospitalist doesn't know how to read a dexa scan report. I can tell that I won't change your mind and you are not the only one and maybe you're right that it's already at that point. I went into medical school to be a doctor but maybe I'm old fashioned.

Medicine is dead.

 

[rokshana]

Medicine is dead the day outpatient internist doesn't know how to recognize and treat an NSTEMI or hospitalist doesn't know how to read a dexa scan report. I can tell that I won't change your mind and you are not the only one and maybe you're right that it's already at that point. I went into medical school to be a doctor but maybe I'm old fashioned.

Treatment for nstemi? Send them to the ED...

 

[GastriqueGraffin]

Sad but true.

Treatment for nstemi? Send them to the ED...

...and consult cardiology. Sigh.

 

[IMreshopeful]

Medicine is dead the day outpatient internist doesn't know how to recognize and treat an NSTEMI or hospitalist doesn't know how to read a dexa scan report. I can tell that I won't change your mind and you are not the only one and maybe you're right that it's already at that point. I went into medical school to be a doctor but maybe I'm old fashioned.

There are already even hospitalists who don’t know how to treat an NSTEMI lol. As a cards fellow at an academic institution we still get reflexive consults for trop elevations like no other...

I remember getting a MICU consult for an NSTEMI on a patient. Peak trop of 8. Guy has ARDS, pancreatitis, renal failure on CRRT, septic shock requiring pressors. Couldn’t get heparinized due to risk of bleeding into abdomen. I saw the consult in less than 2 minutes because we couldn’t do anything for this guy, whether invasive or medical therapy. I ultimately asked the medical residents if they thought I was going to recommend anything different. Their response? “No, we know it’s probably all demand ischemia, but our attending wanted it”. Okay. I spoke to the attending who said “well, legally I wanted to cover my bases and show that a cardiologist had seen the patient”. Has the medicolegal environment become such that you need an expert to comment on a lab value clearly the result of an overwhelming systemic issue? Maybe it has. I don’t know. My point is, I think Medicine might be moving towards pure compartmentalization and not much can likely be done about it.

 

[GastriqueGraffin]

There are already even hospitalists who don’t know how to treat an NSTEMI lol. As a cards fellow at an academic institution we still get reflexive consults for trop elevations like no other...

I remember getting a MICU consult for an NSTEMI on a patient. Peak trop of 8. Guy has ARDS, pancreatitis, renal failure on CRRT, septic shock requiring pressors. Couldn’t get heparinized due to risk of bleeding into abdomen. I saw the consult in less than 2 minutes because we couldn’t do anything for this guy, whether invasive or medical therapy. I ultimately asked the medical residents if they thought I was going to recommend anything different. Their response? “No, we know it’s probably all demand ischemia, but our attending wanted it”. Okay. I spoke to the attending who said “well, legally I wanted to cover my bases and show that a cardiologist had seen the patient”. Has the medicolegal environment become such that you need an expert to comment on a lab value clearly the result of an overwhelming systemic issue? Maybe it has. I don’t know. My point is, I think Medicine might be moving towards pure compartmentalization and not much can likely be done about it.

In a world of only specialists, generalists will be replaced by midlevels in no time. It's happened in other fields and it'll happen to medicine. Hospitalists and PCPs are just a triage. As someone going into fellowship myself, I think the worst part of that is the truly best specialists are also some of the best generalists. You need the whole foundation to really be great IMO.

 

[HoldTheCoffee]

On one hand, I hear your frustration, on the other, I can definitely imagine a scenario where a patient has an adverse event and the hospitalist gets taken to court. I can easily see someone asking, "Do you have cardiologists at your academic hospital? If so why didn't you get a cardiologist to see the patient when there were clear signs of heart damage?" The hospitalist could go into detail about how maybe it wouldn't have changed management, etc., but I'm not sure if the laymen in the jury would really understand that kind of nuance. FWIW I'm also not in general medicine anymore so I've had to pick up consults that also fall into the "cover my bases and get an official note" category and I think that's just where medicine is nowadays, unfortunately.

There are already even hospitalists who don’t know how to treat an NSTEMI lol. As a cards fellow at an academic institution we still get reflexive consults for trop elevations like no other...

I remember getting a MICU consult for an NSTEMI on a patient. Peak trop of 8. Guy has ARDS, pancreatitis, renal failure on CRRT, septic shock requiring pressors. Couldn’t get heparinized due to risk of bleeding into abdomen. I saw the consult in less than 2 minutes because we couldn’t do anything for this guy, whether invasive or medical therapy. I ultimately asked the medical residents if they thought I was going to recommend anything different. Their response? “No, we know it’s probably all demand ischemia, but our attending wanted it”. Okay. I spoke to the attending who said “well, legally I wanted to cover my bases and show that a cardiologist had seen the patient”. Has the medicolegal environment become such that you need an expert to comment on a lab value clearly the result of an overwhelming systemic issue? Maybe it has. I don’t know. My point is, I think Medicine might be moving towards pure compartmentalization and not much can likely be done about it.

 

[IMreshopeful]

In a world of only specialists, generalists will be replaced by midlevels in no time. It's happened in other fields and it'll happen to medicine. Hospitalists and PCPs are just a triage. As someone going into fellowship myself, I think the worst part of that is the truly best specialists are also some of the best generalists. You need the whole foundation to really be great IMO.

Agreed in general... with that in mind I think there’s even a push for there to be hospitalist “fellowships” to better train people in pure inpatient care which honestly, if it reduces wastefulness of consults and resources, would be a good idea to implement. Maybe there would be more thought given to patient care and less “afib with RVR - consult cardiology” or “hyperglycemia - consult endo”

 

[IMreshopeful]

On one hand, I hear your frustration, on the other, I can definitely imagine a scenario where a patient has an adverse event and the hospitalist gets taken to court. I can easily see someone asking, "Do you have cardiologists at your academic hospital? If so why didn't you get a cardiologist to see the patient when there were clear signs of heart damage?" The hospitalist could go into detail about how maybe it wouldn't have changed management, etc., but I'm not sure if the laymen in the jury would really understand that kind of nuance. FWIW I'm also not in general medicine anymore so I've had to pick up consults that also fall into the "cover my bases and get an official note" category and I think that's just where medicine is nowadays, unfortunately.

I think you’re probably right in that this is where we are headed. Just to clarify the attending was a pulm/crit care ICU attending. But even then, I think if you clearly document the logic and can demonstrate that, while a poor prognostic sign, there’s nothing that can be done, if someone took it to court most likely it would be thrown out. There are definitely less extreme examples though...the guy with ESRD and volume overload who has a chronic low level trop elevation and gets a consult because it’s a little higher than normal but no chest pain or EKG changes, though obv volume overload as the cause etc. for example. That will almost certainly get a cards consult. I can see a jury being less impressed with that if an attending doesn’t cover their bases.

Don’t get me wrong...one day in practice this is going to be my bread and butter and an easy consult. But it’s frustrating to see it at an ostensibly academic setting.

 

[GastriqueGraffin]

I agree with both posts above. Defensive medicine leads to a lot of unnecessary waste. I also agree with a 1 year hospitalist fellowship. But I maintain that outpatient medicine is a very important part of medicine residency and should not be brushed off for similar reasons. Also for that reason I like a focused x+y system.

 

[Rhandhali]

One third of your training is required to be outpatient regardless (counting primary care, outpatient electives, and EM as outpatient). It's an accreditation requirement for IM. You're not in hospitalist residency.

And my statement still stands. A third of my training was just pissed away.