Fellow vs Resident-run programs

[FunnyDocMan1234]

This is a distinguishing factor of programs that gets name-dropped a lot (with the assumption that resident-run is better than fellow-run for residency training I would guess) but I have no idea which programs are which and have never heard it mentioned during interview days. So, can anyone share which well known programs around the country are in which category?

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[tryptophan321]

Also no residency program is going to admit that they're at a fellow-run institution, so any insider info from past or current residents would be super helpful. Can anyone comment on Wash U and UChicago specifically?

 

[smartparts]

WashU, at least from the interview day, felt very fellow-run. Some students from there that I interviewed with felt the same way.

In some cases, you want heavy fellow input honestly. I'm at a program that skews towards being fellow-run and 6 months in, I'm still very thankful for that sometimes. Even as a resident, you must do no harm, and I don't know how to manage an intraventricular septal hematoma. It's probably best for all parties involved that I watch over the cardiology fellow's shoulder the first few times rather than be cut loose with a general IM attending at the helm. And believe me, there's no guidelines or UpToDate articles for a lot of the things you'll encounter in your intern year.

 

[obiwan]

when someone mentions a program being fellow run, i feel that it pertains moreso to the ICU/cardiology type rotations especially at places that have the highly super specialized disciplines. for instance, i would imagine a place like Cleveland Clinic would be more fellow run particularly in the CCU.

my training at Parkland was definitely skewed more towards being resident run when it came to MICU and CCU. it was sort of a joke among residents that the cushiest fellowship in our program was pulm/crit care.

 

[buonassezia]

Yes, I got the impression that UTSW was about as resident-run as they come! I got a similar perception of the Bellevue portion of NYU's residency, and Grady Hospital for Emory.

 

[HoldTheCoffee]

Having completed most of residency, the idea that an ICU is mostly "resident run" anywhere actually seems incredibly dangerous to me - do you guys mean that the fellows are not even in the ICU? At my program (which is usually pretty highly regarded), the fellows are generally at least around on the same floor of the hospital to answer questions/help out if we needed. We still get the first stab of coming up with the plan, doing the procedures, etc.

 

[NYsan]

Yes, I got the impression that UTSW was about as resident-run as they come! I got a similar perception of the Bellevue portion of NYU's residency, and Grady Hospital for Emory.

I agree. The programs that had county hospitals all seemed on a whole other level of resident autonomy

 

[obiwan]

Having completed most of residency, the idea that an ICU is mostly "resident run" anywhere actually seems incredibly dangerous to me - do you guys mean that the fellows are not even in the ICU? At my program (which is usually pretty highly regarded), the fellows are generally at least around on the same floor of the hospital to answer questions/help out if we needed. We still get the first stab of coming up with the plan, doing the procedures, etc.

No, there are fellows who are on service with the MICU and definitely if we were really over our heads with what to do for a patient, we could ask them for help but they really took a backseat to the residents. i know that it wasn't not a frequent thing where we are calling the on-call pulm fellow overnight to ask for help (they are not in-house) which i guess was sort of the mentality in our program back then. I remember a fellow in a different subspecialty who had trained at a top tier program was shocked at the autonomy we had in the ICU

 

[bigburrito23]

It confuses me when certain programs and residents brag about huge resident autonomy in their programs. It's always at a hospital that serves a inner city population and lets PGY-1 and 2's make major medical decisions with little oversight, ostensibly because low income patients being hurt by this practice are unlikely to sue the hospital for malpractice.

Seems unethical and parallel to the now discouraged 'medical mission' trips to third world countries for pre-meds in that this practice would never fly for any patient population but the underserved. Moreover, making incorrect medical decisions without anyone more experienced watching over to teach you the right way seems like a poor way to gain skills in residency.

 

[HelpPleaseMD]

It confuses me when certain programs and residents brag about huge resident autonomy in their programs. It's always at a hospital that serves a inner city population and lets PGY-1 and 2's make major medical decisions with little oversight, ostensibly because low income patients being hurt by this practice are unlikely to sue the hospital for malpractice.

Seems unethical and parallel to the now discouraged 'medical mission' trips to third world countries for pre-meds in that this practice would never fly for any patient population but the underserved. Moreover, making incorrect medical decisions without anyone more experienced watching over to teach you the right way seems like a poor way to gain skills in residency.

are you even a resident? Resident autonomy does not imply no supervision... nm i don't even want to comment further.

 

[obiwan]

Moreover, making incorrect medical decisions without anyone more experienced watching over to teach you the right way seems like a poor way to gain skills in residency.

and yet pretty everyone would agree that UTSW is regarded as a strong training program. like HelpPlease said, its not like there is no supervision by upper residents/fellows/attendings but there is difference between hand holding vs allowing you to develop the necessary clinical acumen to be a competent physician

 

[deleted547339]

It confuses me when certain programs and residents brag about huge resident autonomy in their programs. It's always at a hospital that serves a inner city population and lets PGY-1 and 2's make major medical decisions with little oversight, ostensibly because low income patients being hurt by this practice are unlikely to sue the hospital for malpractice.

Seems unethical and parallel to the now discouraged 'medical mission' trips to third world countries for pre-meds in that this practice would never fly for any patient population but the underserved. Moreover, making incorrect medical decisions without anyone more experienced watching over to teach you the right way seems like a poor way to gain skills in residency.

I don't think you're appreciating the big difference between making safe mistakes and unsafe mistakes. There's also the illusion of inadequate supervision which good supervisors can pull off.

 

[IMreshopeful]

It confuses me when certain programs and residents brag about huge resident autonomy in their programs. It's always at a hospital that serves a inner city population and lets PGY-1 and 2's make major medical decisions with little oversight, ostensibly because low income patients being hurt by this practice are unlikely to sue the hospital for malpractice.

Seems unethical and parallel to the now discouraged 'medical mission' trips to third world countries for pre-meds in that this practice would never fly for any patient population but the underserved. Moreover, making incorrect medical decisions without anyone more experienced watching over to teach you the right way seems like a poor way to gain skills in residency.

I'm not sure you have a clue what you're talking about. Resident autonomy does not mean there's no attending in house. It means the attending lets you make decisions and doesn't micromanage your team. It allows you to grow comfort as a clinician and become confident in your decision making. I go to a very resident run program where the fellows and attendings are mostly in a teaching and advisory role and I make the majority of decisions as team senior as long as it's got medical backing. By comparison I know fellows who went to more fellow or attending run programs who are flabbergasted when they see how much our residents know

 

[ArkansasMed]

I'm not sure you have a clue what you're talking about. Resident autonomy does not mean there's no attending in house. It means the attending lets you make decisions and doesn't micromanage your team. It allows you to grow comfort as a clinician and become confident in your decision making. I go to a very resident run program where the fellows and attendings are mostly in a teaching and advisory role and I make the majority of decisions as team senior as long as it's got medical backing. By comparison I know fellows who went to more fellow or attending run programs who are flabbergasted when they see how much our residents know

Well said. Very good explanation of resident vs fellow driven programs. The benefit of resident driven programs is you are just pushed to make decisions under appropriate supervision and you learn a lot. You want this and this can be sudivided further to interns driving plans early or SAR/JARs making plans.

 

[smartparts]

Agree with the comments on UTSW being highly resident-run. Their interns had swagger like seasoned surgery residents.

Also if it wasn't for residents, patients at county hospitals probably wouldn't be getting care at all. Major decisions are made at rounds, after a discussion with the team, not on-the-fly by an intern. And no matter where you go to residency, you're higher-ups/consultants are always there to bounce ideas off of informally.

 

[copperpenny189]

So that being said, other than UTSW being resident run and Cleveland Clinic and Mayo being more attending/ fellow run, can you all name other programs that fit into either category?

 

[smartparts]

So that being said, other than UTSW being resident run and Cleveland Clinic and Mayo being more attending/ fellow run, can you all name other programs that fit into either category?

You'll get a feel for it when you interview. Programs change personality every few years and most places don't fit neatly into either.

 

[dozitgetchahi]

I'm not sure you have a clue what you're talking about. Resident autonomy does not mean there's no attending in house. It means the attending lets you make decisions and doesn't micromanage your team. It allows you to grow comfort as a clinician and become confident in your decision making. I go to a very resident run program where the fellows and attendings are mostly in a teaching and advisory role and I make the majority of decisions as team senior as long as it's got medical backing. By comparison I know fellows who went to more fellow or attending run programs who are flabbergasted when they see how much our residents know

Actually, it may indeed mean that there's no attending in house...at our VA and county hospital, I'm the 'staff' at night...there's no attending around. Period. This is how you grow up and learn how to handle things, and yes it's better for you then having staff looking over you constantly.

 

[Raryn]

Actually, it may indeed mean that there's no attending in house...at our VA and county hospital, I'm the 'staff' at night...there's no attending around. Period. This is how you grow up and learn how to handle things, and yes it's better for you then having staff looking over you constantly.

That's how it is in our hospitals as well. I won't identify my program, but neither the fellow nor the attending are in house overnight for any of our primary services, including our ICU. I'm (as a PGY3) cross-covering 20 ICU patients right now, did two lines so far tonight, and have seen three consults that I made the decision whether they'll be coming to the unit overnight. I denied one of them a transfer to the unit, and my decision stands as definitive until the patient is staffed in the AM. The only other person in-house for ICU right now is the PGY2 I'm on with, and she's covering the other half of the patients. Not doing consults currently as we're trying to alternate days to allow the other to leave early, but tomorrow that will be her job. We spitball ideas off each other. Both fellow and attending are available by phone if necessary and both are rarely called. That said, they will come in if asked.

For our floor patients, theoretically the on-call attending can also be called at any time. I've never heard of anyone calling them. There is also a different academic attending technically in-house covering their own patients (a service our attendings round on when they're not on our academic teams) that is available if the PGY2+1 covering the floors have any urgent questions or need supervision for a procedure, but that attending is rarely utilized. I can count on one hand when I called them when I was covering wards at night last year, and that's because it was one of our chiefs that I was asking to supervise me doing a procedure as a favor. If the floor cross-coverage people really need urgent help, they walk across the bridge and consult with the residents covering the ICU service. Otherwise, we learn how to take care of our patients and present them the following morning.

Edit: Oh, and we're responsible for all the code blues in the hospital too. Including the ones on the completely non-academic hospitalist services. The hospitalists, who aren't our faculty, stick around long enough to give us a blurb on why the patient was there... and disappear mid-code.

 

[HelpPleaseMD]

i am quite sure the discussion regarding inhouse physicians applied to the AM.

 

[UTlonghorn]

WashU, at least from the interview day, felt very fellow-run. Some students from there that I interviewed with felt the same way.

In some cases, you want heavy fellow input honestly. I'm at a program that skews towards being fellow-run and 6 months in, I'm still very thankful for that sometimes. Even as a resident, you must do no harm, and I don't know how to manage an intraventricular septal hematoma. It's probably best for all parties involved that I watch over the cardiology fellow's shoulder the first few times rather than be cut loose with a general IM attending at the helm. And believe me, there's no guidelines or UpToDate articles for a lot of the things you'll encounter in your intern year.

I rarely post on here but had to chime in on this one. I'm a Wash U resident. Wash U is very much resident-run. If we're talking about the ICU in particular, we are on q3 30 hour call as residents, place all the lines, adjust the drips, work with RT to adjust the vents, cross-cover the entire unit, run the codes, hold the ICU triage phone to decide on who gets admitted, and while there is typically a fellow on site, we as residents make most of the decisions. If anything, we just run certain decisions by a fellow if they're available. In the CCU, there were nights when I never saw a fellow. We paged them when we needed help but the fellow was running around the hospital covering the ED and essentially the entire hospital so they often were not in the ICU. I've never heard of Wash U being referred to as fellow-run. Fellows are definitely available if you need them though.

 

[IMreshopeful]

Actually, it may indeed mean that there's no attending in house...at our VA and county hospital, I'm the 'staff' at night...there's no attending around. Period. This is how you grow up and learn how to handle things, and yes it's better for you then having staff looking over you constantly.

I'm well aware of that. The only in house attending for medicine is our MICU attending as we have a 24 hr staffing. Medicine at both our main hospitals and VA are residents only at night on every other service. I was referring to the daytime attendings providing adequate supervision and counseling as I noted before.

 

[ArkansasMed]

That's how it is in our hospitals as well. I won't identify my program, but neither the fellow nor the attending are in house overnight for any of our primary services, including our ICU. I'm (as a PGY3) cross-covering 20 ICU patients right now, did two lines so far tonight, and have seen three consults that I made the decision whether they'll be coming to the unit overnight. I denied one of them a transfer to the unit, and my decision stands as definitive until the patient is staffed in the AM. The only other person in-house for ICU right now is the PGY2 I'm on with, and she's covering the other half of the patients. Not doing consults currently as we're trying to alternate days to allow the other to leave early, but tomorrow that will be her job. We spitball ideas off each other. Both fellow and attending are available by phone if necessary and both are rarely called. That said, they will come in if asked.

For our floor patients, theoretically the on-call attending can also be called at any time. I've never heard of anyone calling them. There is also a different academic attending technically in-house covering their own patients (a service our attendings round on when they're not on our academic teams) that is available if the PGY2+1 covering the floors have any urgent questions or need supervision for a procedure, but that attending is rarely utilized. I can count on one hand when I called them when I was covering wards at night last year, and that's because it was one of our chiefs that I was asking to supervise me doing a procedure as a favor. If the floor cross-coverage people really need urgent help, they walk across the bridge and consult with the residents covering the ICU service. Otherwise, we learn how to take care of our patients and present them the following morning.

Edit: Oh, and we're responsible for all the code blues in the hospital too. Including the ones on the completely non-academic hospitalist services. The hospitalists, who aren't our faculty, stick around long enough to give us a blurb on why the patient was there... and disappear mid-code.

Sounds identical to our MICU setup.

 

[Instatewaiter]

Heirarchy of resident run from most to least:
No fellows in house- you are forced to make all decisions
Fellows in house and discuss only when needed. Otherwise not seen or heard from
Fellows in house where plans are discussed on each patient
Fellows in house and they are very involved and run the show.

Sounds identical to our MICU setup.

Sounds like my prior MICU setup. Pretty sure I was part of the same imperturbable program as you are now a part of.

 

[Doctor Bob]

I rarely post on here but had to chime in on this one. I'm a Wash U resident. Wash U is very much resident-run. If we're talking about the ICU in particular, we are on q3 30 hour call as residents, place all the lines, adjust the drips, work with RT to adjust the vents, cross-cover the entire unit, run the codes, hold the ICU triage phone to decide on who gets admitted, and while there is typically a fellow on site, we as residents make most of the decisions. If anything, we just run certain decisions by a fellow if they're available. In the CCU, there were nights when I never saw a fellow. We paged them when we needed help but the fellow was running around the hospital covering the ED and essentially the entire hospital so they often were not in the ICU. I've never heard of Wash U being referred to as fellow-run. Fellows are definitely available if you need them though.

I suppose it depends on how you define "run".
In the absence of the attending, the treatment plan is determined by a resident in a resident run program.
In the absence of the attending, the treatment plan is determined by a fellow in a fellow run program.

In that regard, Wash U is very much a fellow run program.

There is 24 hour fellow coverage in the MICU, SICU, and CTICU by critical care fellows. There is 8 hour coverage by critical care fellows in the CCU and 24 hour coverage by cardiology fellows. There is 24 hour coverage by either a critical care fellow or a neurocritical care fellow in the neuroICU.

Residents do -not- place all the lines in the ICU. Right of first refusal for all procedures go to the fellow and any procedures done by residents in the ICU have to be supervised by an attending or the fellow by ICU policy.
In the MICU, we give the residents a bit more free-reign at night because there is one critical care fellow for 34 beds. Big treatment strategy plans still have to run through us and we are certainly there for all codes or significant status changes.

 

[ArkansasMed]

This is a distinguishing factor of programs that gets name-dropped a lot (with the assumption that resident-run is better than fellow-run for residency training I would guess) but I have no idea which programs are which and have never heard it mentioned during interview days. So, can anyone share which well known programs around the country are in which category?

I realized no one really answered your question.

Every resident who posts here is going to claim their program is resident run as said before. It's a "pride" thing. For those interviewing you can get the answer to this question by asking how Certain rotations with fellows present are run. For example, "how is the typical day in the MICU?" Is there an attending or fellow present overnight working with you? If your on your own at night it's 99% certain it's a resident run program. Likewise, if they say a fellow sees all new admissions overnight you can probably confidently state that residents do not have as much autonomy as other programs. Same with floors. There are extremes. Some programs always have an in house attending overnight with a ton of senior residents over with the interns to some where interns are left alone to manage a whole service after about month 3 of residency (with one resident covering say 7 or so services). I'd say that should be your best gauge to true autonomy as a resident.

 

[IMreshopeful]

I realized no one really answered your question.

Every resident who posts here is going to claim their program is resident run as said before. It's a "pride" thing. For those interviewing you can get the answer to this question by asking how Certain rotations with fellows present are run. For example, "how is the typical day in the MICU?" Is there an attending or fellow present overnight working with you? If your on your own at night it's 99% certain it's a resident run program. Likewise, if they say a fellow sees all new admissions overnight you can probably confidently state that residents do not have as much autonomy as other programs. Same with floors. There are extremes. Some programs always have an in house attending overnight with a ton of senior residents over with the interns to some where interns are left alone to manage a whole service after about month 3 of residency (with one resident covering say 7 or so services). I'd say that should be your best gauge to true autonomy as a resident.

Yes, we are aware that Hopkins gives their interns free reign. That does not make models where an in house MICU attending and fellow are present any less resident run. It's all about the degree of autonomy in decision making that is present. Conversely having no fellow or attending in house but having to call them for critical care decisions can be just as fellow or attending heavy a program. It's very much about the culture. Much like Hopkins my upper mid tier program allows a LOT of responsibility and free reign to the interns and we have an immensely sick and complex patient population.

 

[Instatewaiter]

Yes, we are aware that Hopkins gives their interns free reign. That does not make models where an in house MICU attending and fellow are present any less resident run.

Actually, that is exactly what happens when the MICU attending and fellow are present. You aren't running the show overnight. You are going to staff things overnight, you are going to ask them questions instead of thinking it through on your own and laying your nickel down. Those programs that keep the attending there are basically saying they don't want (or trust) the residents to run the show overnight.

 

[hotchik]

If you're not confident, you will ALWAYS be asking your fellow or attending for advice or confirmation with your plan. I've seen this vary between residents (the smart ones vs the stupid ones)

If you're confident/cocky, you will just do what you want -- as I became more confident/comfortable taking care of patients, I stopped "running things" by fellows or attendings and I just do things on my own...then they either yell at me or applaud me and I look like a boss in the morning... lol

You need this attitude to learn in residency...if you screw up...its the attendings faault....

 

[ArkansasMed]

Yes, we are aware that Hopkins gives their interns free reign. That does not make models where an in house MICU attending and fellow are present any less resident run. It's all about the degree of autonomy in decision making that is present. Conversely having no fellow or attending in house but having to call them for critical care decisions can be just as fellow or attending heavy a program. It's very much about the culture. Much like Hopkins my upper mid tier program allows a LOT of responsibility and free reign to the interns and we have an immensely sick and complex patient population.

I am not sure why or how Hopkins is involved in the conversation. To be fair, our interns don't admit on the MICU, this is left to the JAR/SAR.

There are a ton of programs that offer equal autonomy to the interns and residents and train exceptional future attendings. I stand by my word that not having a fellow or attending in house forces you to make the call, makes you grow up and ultimately, the plan you present in the morning was your plan. You most likely went with that plan, whether crappy or not, for hours before the fellow or attending offers their input.

 

[235009]

Actually, that is exactly what happens when the MICU attending and fellow are present. You aren't running the show overnight. You are going to staff things overnight, you are going to ask them questions instead of thinking it through on your own and laying your nickel down. Those programs that keep the attending there are basically saying they don't want (or trust) the residents to run the show overnight.

Having an attending in house provides variable supervision overnight depending on who it is. When it's a pulm/CC attending they tend to be very involved but when the micu is staffed by a cardiologist or anesthesiologist at night as it sometimes is at my program you tend to get much more autonomy those days.

 

[UTlonghorn]

I suppose it depends on how you define "run".
In the absence of the attending, the treatment plan is determined by a resident in a resident run program.
In the absence of the attending, the treatment plan is determined by a fellow in a fellow run program.

In that regard, Wash U is very much a fellow run program.

There is 24 hour fellow coverage in the MICU, SICU, and CTICU by critical care fellows. There is 8 hour coverage by critical care fellows in the CCU and 24 hour coverage by cardiology fellows. There is 24 hour coverage by either a critical care fellow or a neurocritical care fellow in the neuroICU.

Residents do -not- place all the lines in the ICU. Right of first refusal for all procedures go to the fellow and any procedures done by residents in the ICU have to be supervised by an attending or the fellow by ICU policy.
In the MICU, we give the residents a bit more free-reign at night because there is one critical care fellow for 34 beds. Big treatment strategy plans still have to run through us and we are certainly there for all codes or significant status changes.

Thanks for your response Dr. Bob. I think the confusion probably stems from inconsistent definitions of "resident-run". You are absolutely right if we go by the way you have defined it. Yours is a very clear definition and maybe the one we should be using. I was thinking of it more as a spectrum of how much responsibility, overnight autonomy or "free-reign" as you have called it, and procedural access the resident is entitled to. While fellows are available, compared to certain programs, I feel that we still have a fairly high level of overall autonomy and the chance to at least try procedures first. From friends I have talked to in other programs, this is not always typical. And of course big-treatment plans still go through the fellow. In the CCU in particular though, there were numerous nights when there was a STEMI or multiple simultaneous consults that kept the fellow occupied for most of the night, and we would make decisions on our own.

 

[Doctor Bob]

Those programs that keep the attending there are basically saying they don't want (or trust) the residents to run the show overnight.

Well... it may be a little more nuanced than that. There are also billing issues that come into play. If a procedure is done and a resident does it without the attending present, then they can't bill for it. If however the attending is present, then they can bill for it. A patient that gets admitted before midnight and gets a critcare H&P can then also get a critcare daily note the next day; that's more billing.

I stand by my word that not having a fellow or attending in house forces you to make the call, makes you grow up and ultimately, the plan you present in the morning was your plan. You most likely went with that plan, whether crappy or not, for hours before the fellow or attending offers their input.

I agree with this. At my residency program we didn't have fellows. And the attendings went home and went to sleep. So we were it. Right or wrong we set the plan for the night. In the morning I'd sometimes get the "what the heck were you thinking" talk. But as long as I could justify my line of thought (right or wrong), it turned out ok. There are lots of ways to treat patients and they have the same outcome in 24/48/72 hours.
I try (sometimes unsuccessfully) to be hands off when I'm the overnight fellow. As long as your plan isn't dangerous, counterproductive, or contraindicated, I'll let you go ahead with it. It might not be the way that I would treat the person, but the residents aren't going to develop their own practice style if I'm always saying "ok, do A, then B, then C."

Thanks for your response Dr. Bob. I think the confusion probably stems from inconsistent definitions of "resident-run". You are absolutely right if we go by the way you have defined it. Yours is a very clear definition and maybe the one we should be using. I was thinking of it more as a spectrum of how much responsibility, overnight autonomy or "free-reign" as you have called it, and procedural access the resident is entitled to. While fellows are available, compared to certain programs, I feel that we still have a fairly high level of overall autonomy and the chance to at least try procedures first. From friends I have talked to in other programs, this is not always typical. And of course big-treatment plans still go through the fellow. In the CCU in particular though, there were numerous nights when there was a STEMI or multiple simultaneous consults that kept the fellow occupied for most of the night, and we would make decisions on our own.

The CCU is the wild west, and definitely the place where IM residents have the most free reign overnight.
In a program where fellows are ominpresent, the experience for the residents will vary wildly based on what sort of background and personality the fellows have. If they aren't confident in their own ability they're likely to be more micromanagering and it'll feel like residents don't have any say in the treatment plan. My take on things is that there is very little you can do to a patient that I can't reverse or stabilize so go ahead and enact your plan. Let's see what happens, and then you'll learn better from the experience whether you were right or wrong.
I think the best fellow run programs are the ones where the residents feel like it's a resident run program. If the residents feel like it's a fellow run program, then the fellows have failed in their supervisory role.

 

[hotchik]

are hospitals even allowed have ICUs open without a physician in house? wonder what the public would say knowing the sickest ppl are being cared for by interns and residents at these hospitals...lol

 

[gutonc]

are hospitals even allowed have ICUs open without a physician in house? wonder what the public would say knowing the sickest ppl are being cared for by interns and residents at these hospitals...lol

You're joking, right? At most community hospitals, you're lucky if you have 1 hospitalist, 1 ER doc and 1 anesthesiologist in house overnight. Interns and residents would be a huge bonus.

The main hospital where I work has an IM residency (and hosts surgery residents from the University). Overnight there is a resident/intern team, a non-teaching hospitalist, 1 ED doc and an anesthesiologist on the OB floor. This is a 250+ bed hospital.

 

[Instatewaiter]

Well... it may be a little more nuanced than that. There are also billing issues that come into play. If a procedure is done and a resident does it without the attending present, then they can't bill for it. If however the attending is present, then they can bill for it. A patient that gets admitted before midnight and gets a critcare H&P can then also get a critcare daily note the next day; that's more billing.

Yes I am sure the attendings were clammoring to bill more in the middle of the night... But you are right you do bill more.

 

[visari]

resident autonomy is a very vague term. Whether there's a fellow or intesivist at night in the ICU or CCU doesn't automatically translate into being a fellow-run program. When I was a PGY3 and doing MICU nights, there was always a fellow and intesivist at night. The fellow is responsible for accepting patients to the ICU but he's not managing everything. We would intubate or do the lines and proceed with the plans. The intesivist is usually asleep and we would staff the patient when he wakes up. The fellow is there as a back up if somebody codes while you're doing a procedure in a different room or if 3-4 patients hit the unit at once and they all need procedures. But it was never like I had to go ask the fellow if I wanted to give somebody lasix or fluids or antibiotics or titrate pressors or sedation. I don't feel like this setup made me a lazy incompetent resident as some folks here think.

Patients in the ICU are often mismanaged not because of lack of knowledge but lack of experience. So I don't buy this "if there's supervision inhouse, you're going to ask them rather than thinking and reading and coming up with a plan". if you like to be micromanaged then you will find ways to ask people for help whether they're inhouse or not and the opposite is true. When there's a complicated ICU situation, it's not usually something that you can just pull up a paper from pubmed or an article on uptodate and figure out the solution from there. It's rather a situation where you need somebody who is a little more experienced than a PGY-2 or PGY-3 to handle. That's OK guys. You're not the masterminds of critical care medicine yet. It's ok if you ask for help in cases like that. it doesn't make you a better resident if you come up with a plan on your own and it turns up to be a disaster. The patient's family are not going to appreciate the fact that screwing up is part of your learning curve.

It's also different if you're at a community or a small academic hospital where you get the run of the mill septic shock or respiratory failure or GI bleeds that residents should feel comfortable managing, or at a tertiary referral hospital where you can get extremely complicated and sick patients either from the ER or flown from hospitals around town. Those sometimes can't wait 8 hours before somebody comes in in the morning to make sure the resident did everything right.

I think about this way: if a family member of mine is extremely sick and needs ICU care, I would be fine with a competent resident taking care of them but I would feel way more comfortable knowing that there are more experienced people available inhouse and supervising what he/she doing overnight.

 

[Siggy]

are hospitals even allowed have ICUs open without a physician in house? wonder what the public would say knowing the sickest ppl are being cared for by interns and residents at these hospitals...lol

Overnight at my hospital it's an intern, a resident, and an EM physician in house. There's an intensivist and IM attending available by phone... and in some cases the intensivist is close enough to come in if needed.

 

[rokshana]

are hospitals even allowed have ICUs open without a physician in house? wonder what the public would say knowing the sickest ppl are being cared for by interns and residents at these hospitals...lol

have you done ANY clinical work?

 

[deleted547339]

resident autonomy is a very vague term. Whether there's a fellow or intesivist at night in the ICU or CCU doesn't automatically translate into being a fellow-run program. When I was a PGY3 and doing MICU nights, there was always a fellow and intesivist at night. The fellow is responsible for accepting patients to the ICU but he's not managing everything. We would intubate or do the lines and proceed with the plans. The intesivist is usually asleep and we would staff the patient when he wakes up. The fellow is there as a back up if somebody codes while you're doing a procedure in a different room or if 3-4 patients hit the unit at once and they all need procedures. But it was never like I had to go ask the fellow if I wanted to give somebody lasix or fluids or antibiotics or titrate pressors or sedation. I don't feel like this setup made me a lazy incompetent resident as some folks here think.

Patients in the ICU are often mismanaged not because of lack of knowledge but lack of experience. So I don't buy this "if there's supervision inhouse, you're going to ask them rather than thinking and reading and coming up with a plan". if you like to be micromanaged then you will find ways to ask people for help whether they're inhouse or not and the opposite is true. When there's a complicated ICU situation, it's not usually something that you can just pull up a paper from pubmed or an article on uptodate and figure out the solution from there. It's rather a situation where you need somebody who is a little more experienced than a PGY-2 or PGY-3 to handle. That's OK guys. You're not the masterminds of critical care medicine yet. It's ok if you ask for help in cases like that. it doesn't make you a better resident if you come up with a plan on your own and it turns up to be a disaster. The patient's family are not going to appreciate the fact that screwing up is part of your learning curve.

It's also different if you're at a community or a small academic hospital where you get the run of the mill septic shock or respiratory failure or GI bleeds that residents should feel comfortable managing, or at a tertiary referral hospital where you can get extremely complicated and sick patients either from the ER or flown from hospitals around town. Those sometimes can't wait 8 hours before somebody comes in in the morning to make sure the resident did everything right.

I think about this way: if a family member of mine is extremely sick and needs ICU care, I would be fine with a competent resident taking care of them but I would feel way more comfortable knowing that there are more experienced people available inhouse and supervising what he/she doing overnight.

You're intubating without supervision? That seems.....less than ideal for patient care.