Feeling intensely worried about continuing residency - common thoughts or uncommon misgivings?

[ExcaliburPrime1]

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I'm not sure if it is related to my program, myself, or some combination of the two, but I feel really worried and seriously considering giving up.

Unlike my medical school training, my program seems incredibly hands-off in terms of attending physician oversight, to the point that I feel unsafe, both for myself and my patients. I feel like the main goal, both in my psychiatry and medicine rotations, has been to discharge the patient at any cost. No one cares about them feeling better, few believe they'll actually make follow-up appointments, and no one has the time to explain what is going on.

Of course, I do my best, but when I'm asked to discharge someone on my first day at a rotation when they've been in the hospital for a week and nothing has been done in terms of follow-up and there doesn't even seem to be a coherent plan of what they were doing in the hospital, then it gets extremely challenging. Even after I have adjusted to each rotation, I always feel on-edge, with no one really in charge, with plans that come out of thin air, and it's not a good feeling.

I've tried to communicate this with colleagues on a low-level, informally and in no-stakes sort of bull****ting sessions, but I can't get a read as to whether or not they feel the same, and so I begin to question if it's "user error" and that I'm just missing something that everyone else seems to be fine with. I just know that if it was my mom or brother who was in the hospital, either in the psych ward or medical floor, that I would not want their experience to mirror that of many of my patients. 🙁

 

[deleted480308]

Do you think the patients will get better care if you leave?

You describe a situation in which other don't care...I'd suggest staying and caring

 

[deleted314290]

What year are you in the program? pgy1?

 

[24blue8]

I am an intern. That doesn't sound like what I am experiencing but I don't know what's "normal". I feel like my patients aren't discharged unless there is a ridiculous amount of planning set up in place. We do so much coordinating and arranging follow up it's startling at times and what I assumed was due to a litiginous atmosphere. What the patient does when they leave is up to them but we even call the next day to check on people who are discharged from the ED...
If I don't understand why the patient is being discharged I ask and get a good explanation. But I haven't discharged someone and feared for them on the outside. We work the hell up out of people here. Futility be damned hah...

 

[LasVagus]

I can't speak for the medicine service at my program because it's been too long since I've done a rotation with them, but the aftercare planning on the psychiatry service at my residency is usually quite thorough. Per protocol, no one is discharged without a follow-up appointment with a PCP, psychiatrist, and therapist. If they don't currently have any of those providers (and they often aren't set up with any outpatient providers), the social worker will find a PCP and/or psychiatrist and/or therapist for them. We do this even if the patient does not want them ("I'm telling you I don't need a therapist or a PCP! I just need a psychiatrist to get me meds!"). They often get referred to the residency clinic for aftercare and they show up to the intake about 40% of the time. We give them a call at their appointment time when they don't show up and offer to reschedule. We then send a letter. I feel bad when they don't show up, but there's only so much I can do. Time is a precious resource and we have lots of people to try to help.

Much of medicine these days has a bit of a factory-like/conveyor belt feel to it. It can seem quite cold and detached at times. But I swear to you that there is still a beating heart underneath all of the bureaucratic nonsense. I wouldn't give up on the world of medicine just yet. We need people like you who care🙂.

 

[Shikima]

Medicine has turned into an assembly line with busy work to keep the lawyers at bay.

 

[thoffen]

Of course, I do my best, but when I'm asked to discharge someone on my first day at a rotation when they've been in the hospital for a week and nothing has been done in terms of follow-up and there doesn't even seem to be a coherent plan of what they were doing in the hospital, then it gets extremely challenging.

Are people being discharged without any kind of follow-up plan/appointment (unless they explicitly refused)? That's hard to imagine, but I'd also say it's below standard of care unless you can clearly state why the patient doesn't need follow-up.

It's really hard for us to judge your program, though. I'd recommend reaching out to one of the senior residents and getting their perspective.

Otherwise, giving up and leaving residency or trying to transfer could be extremely hazardous to your future.

 

[F0nzie]

Having genuine interest in the welfare of your patients while everybody else around you is checked out is common. Don't let others' inadequacies influence your actions or shake your core beliefs. These people are average and feed off of each other to feel better about themselves. If you want to join their ranks think about yourself more, take shortcuts, skim by, and say nothing.


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[J ROD]

It's all about moving the meat.........

 

[Shikima]

It's all about moving the meat.........

Assembly line work. Whether you are putting widgets together or people. It's the same. The more you see, despite the quality, the better you look.

 

[smalltownpsych]

I'm not sure if it is related to my program, myself, or some combination of the two, but I feel really worried and seriously considering giving up.

Unlike my medical school training, my program seems incredibly hands-off in terms of attending physician oversight, to the point that I feel unsafe, both for myself and my patients. I feel like the main goal, both in my psychiatry and medicine rotations, has been to discharge the patient at any cost. No one cares about them feeling better, few believe they'll actually make follow-up appointments, and no one has the time to explain what is going on.

Of course, I do my best, but when I'm asked to discharge someone on my first day at a rotation when they've been in the hospital for a week and nothing has been done in terms of follow-up and there doesn't even seem to be a coherent plan of what they were doing in the hospital, then it gets extremely challenging. Even after I have adjusted to each rotation, I always feel on-edge, with no one really in charge, with plans that come out of thin air, and it's not a good feeling.

I've tried to communicate this with colleagues on a low-level, informally and in no-stakes sort of bull****ting sessions, but I can't get a read as to whether or not they feel the same, and so I begin to question if it's "user error" and that I'm just missing something that everyone else seems to be fine with. I just know that if it was my mom or brother who was in the hospital, either in the psych ward or medical floor, that I would not want their experience to mirror that of many of my patients. 🙁

The system doesn't really want patients to get better. Sure there are some systems that are better than others, but no large unfeeling system is really healthy for the individual patient. A doctor or any other human who cares is helpful, but if they aren't careful and self-aware they too can become either a tool of the system or just another casualty.

 

[clozareal]

If I was in your situation, this would be the time to bring up your concerns (with specific examples) to your program director and/or assistant program director(s) for starters. I would then scale up if I wasn't satisfied with my answer.

 

[Merovinge]

If I was in your situation, this would be the time to bring up your concerns (with specific examples) to your program director and/or assistant program director(s) for starters. I would then scale up if I wasn't satisfied with my answer.

This is likely to get you into serious hot water. Finding a sympathetic attending or resident and working on how you can still do your best for patients in a (potentially) broken system is a much safer bet, particularly as an intern when the exact way the machine works is likely a black box.

 

[clozareal]

This is likely to get you into serious hot water. Finding a sympathetic attending or resident and working on how you can still do your best for patients in a (potentially) broken system is a much safer bet, particularly as an intern when the exact way the machine works is likely a black box.

How will the residency training program improve if residents don't give feedback on what needs to be improved upon? I mean, you're not going to change institutional practice quickly or get new facilities for these patients, but if the rotations that you're on aren't educational, they might be open to structuring in some units with better faculty/structure for residents to rotate on.

But you bring up a good point. If the residency program administration or the system you're in in general is broken, then I agree with merovinge in going to a peer mentor or attending that isn't involved in the program/evaluating you on what you could do.


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[Shikima]

No one cares what a resident thinks in training. You're there only to do the work and will be beat if you don't score well enough on the ITE.

 

[splik]

How will the residency training program improve if residents don't give feedback on what needs to be improved upon?

so naive, so idealistic. those residents who told you that their program was responsive to feedback were probably lying... I'm not saying it never happens but it is the exception that proves the rule. Usually the program directors don't have any power to deal with systems issues/attendings etc. My first training director was wonderful at providing supportive psychotherapy for the residents and empathizing with the struggle but did nothing about the actual issue. My next one was masterful as gaslighting and blaming everything on the resident. When residents talked about wanting to transfer or switch specialty, they never tried to talk them out of it and immediately found someone to replace their spot.

Other common political techniques of residency programs are for attendings to all join forces to scapegoat the resident who becomes the identified patient, creating useless committees or taskforce to address the issues which take years to come up with some report that is never acted upon, creating useless surveys to solicit feedback for the sake of collecting feedback, having resident meetings or focus groups or "meeting with the PD" so residents can feel heard (but never listened to), having some sort of process group for residents to discuss their concerns (but ignoring it), forcing the resident in question into therapy/counseling, or my personal favorite, turning the complaining resident into a chief so they are forced to identify with their abuser and then used to oppress their fellow residents...

 

[Shikima]

so naive, so idealistic. those residents who told you that their program was responsive to feedback were probably lying... I'm not saying it never happens but it is the exception that proves the rule. Usually the program directors don't have any power to deal with systems issues/attendings etc. My first training director was wonderful at providing supportive psychotherapy for the residents and empathizing with the struggle but did nothing about the actual issue. My next one was masterful as gaslighting and blaming everything on the resident. When residents talked about wanting to transfer or switch specialty, they never tried to talk them out of it and immediately found someone to replace their spot.

Other common political techniques of residency programs are for attendings to all join forces to scapegoat the resident who becomes the identified patient, creating useless committees or taskforce to address the issues which take years to come up with some report that is never acted upon, creating useless surveys to solicit feedback for the sake of collecting feedback, having resident meetings or focus groups or "meeting with the PD" so residents can feel heard (but never listened to), having some sort of process group for residents to discuss their concerns (but ignoring it), forcing the resident in question into therapy/counseling, or my personal favorite, turning the complaining resident into a chief so they are forced to identify with their abuser and then used to oppress their fellow residents...

Stockholm syndrome - become an attending at the program.

 

[Liquid8]

When I read the OP, it sounds like therapeutic nihilism is ingrained in their workplace. While you probably aren't going to implement any widespread institutional change, you can still make what you consider to be appropriate management plans - and I'd say arranging followup is generally appropriate unless a patient explicitly refuses, which should be documented in any case.

The other aspect is there may be a supervisor mismatch. While some doctors thrive with limited direct supervision, I get the sense that the OP prefers slightly more oversight at this early stage. Personally the best supervisors I had were the ones who let me make the majority of treatment decisions but were available to discuss things if required. OTOH, some prefer the micro-manager types who want everything run by them.

so naive, so idealistic. those residents who told you that their program was responsive to feedback were probably lying... I'm not saying it never happens but it is the exception that proves the rule.

I had this experience, and to this day I'm still shocked it happened.

I remember at a six monthly review session, one of the directors told me that he wanted to make our service a desirable place to train and wanted to know what I thought needed to change to make the inpatient job more attractive. From my point of view, we just needed an additional junior doctor to manage the workload as we had no cover arrangements and often had issues when someone went on leave. As a natural cynic I didn’t believe anything would actually change, so I was very surprised the next year when I found out that all the inpatient teams had been allocated an extra doctor.

 

[inquiringmind1]

You learn by seeing patients, making mistakes, and then not repeating them. The need for an attending to hold your hand and tell you what to do prob makes bad residents not good ones.

 

[Merovinge]

so naive, so idealistic. those residents who told you that their program was responsive to feedback were probably lying... I'm not saying it never happens but it is the exception that proves the rule. Usually the program directors don't have any power to deal with systems issues/attendings etc. My first training director was wonderful at providing supportive psychotherapy for the residents and empathizing with the struggle but did nothing about the actual issue. My next one was masterful as gaslighting and blaming everything on the resident. When residents talked about wanting to transfer or switch specialty, they never tried to talk them out of it and immediately found someone to replace their spot.

Other common political techniques of residency programs are for attendings to all join forces to scapegoat the resident who becomes the identified patient, creating useless committees or taskforce to address the issues which take years to come up with some report that is never acted upon, creating useless surveys to solicit feedback for the sake of collecting feedback, having resident meetings or focus groups or "meeting with the PD" so residents can feel heard (but never listened to), having some sort of process group for residents to discuss their concerns (but ignoring it), forcing the resident in question into therapy/counseling, or my personal favorite, turning the complaining resident into a chief so they are forced to identify with their abuser and then used to oppress their fellow residents...

Wish I had read/known this before starting residency. Something about all these people always saying how open programs are to feedback/change and my baseline optimism crashed into a brick wall by PGY2 year. Thankfully we get trained to identify once the gaslighting and scapegoating start fast enough to hightail it back towards laying low. Its always interesting having conversations at the bar with numerous other residents in your program who have had the exact same experience, makes it all a lot easier to go though.