For kaiser permanente los angeles internal med applicants (prelim & categorical)

[rdsx]

To PRELIM and CATEGORICAL Applicants for INTERNAL MEDICINE RESIDENCY AT KAISER PERMANENTE LOS ANGELES. It’s no longer the program it used to be…

The Internal Medicine Residency Program at Kaiser Los Angeles has changed significantly in the past 3 years. Once a major attraction to both prelim and categorical applicants for its great lifestyle during residency while still providing a great educational training experience, the program director has made a number of policy changes recently that have basically negated this attraction of “lifestyle.” Additionally, there are major flaws in the Kaiser system that add unnecessary stress and work on the residents, and these flaws have been present for the last 3 yrs (at least!). Yet nothing has been done to correct them despite attempts at discussion with administration. See Below:

1) The program director has made 3 major additions to call responsibilities over the last 2.5 years, ALL of which were made AFTER the start of the academic year WITHOUT discussion with residents.

Call nights have increased in length with violation of ACGME regulations (for which the program director has somehow got an exemption). Residents are now required to do extra ED admitting shifts in the winter during non-call months (see #3, below). And interns are now covering easily over 100 patients when on call, with a number of these patients so unstable that they are on the brink of ICU transfer.

Regarding this last change: imagine yourself as an intern covering over 100 patients on your first call night ALONE. Some interns have completed this shift literally shaking and overwhelmed, ready to quit the program. Although you might be told during interviews that an R2 and R3 are available to help on these shifts, they are saddled with their own responsibilities covering a very active ICU and CCU. This is a program where you learn via Trial by Fire, at the expense of patient care. BTW, I would NOT advise sending loved ones to Kaiser Permanente Los Angeles between the months of July and September, unless you want inexperienced, unsupervised interns managing them at night.

What has especially irked many residents is that these policy changes are implemented during the middle of the academic year, without discussion with residents. This way, it’s like the program director “traps” residents in the program, so that they HAVE to follow these new policy changes once they sign their contract. However, he never tells the incoming interns or residents of these plans, but changes them arbitrarily. It is deceitful and dishonest.

2) Numerous BOGUS admissions to be worked up by residents without proper screening by attendings

Prior to delving into this problem, the Kaiser system of “partnership” needs to be explained. Newly-hired attendings need to work for 3 years at Kaiser before they can be considered to become a “Kaiser Partner,” which is reaped with benefits like long-term stable employment, great retirement perks, etc. For a new-hire to become a partner, the existing partners need to vote on him/her, so it behooves the new-hires to please the established partners. Many of the IM attendings that admit from the ED are new; while many of the ED attendings are already partners. AND the ED at Kaiser LAMC is notoriously bad (they don’t work up patients properly, write poor incomplete ED notes, make wrong diagnoses, etc). This combination of sub-par ED attendings (who are partners) telling new IM attendings to admit certain ED patients, means that residents end up admitting things like constipation, dizziness due to decreased fluid intake, Irritable Bowel Disease, etc (ALL of which can be managed within a matter of hours in the ED or outpatient setting, WITHOUT an overnight admission). It is VERY common for residents to admit a patient one night, and then discharge that patient the next morning...thereby wasting everyone’s resources…with the resident doing all the paperwork. If you want to be become a glorified secretary writing H&P’s and Discharge summaries all day, without the benefit of learning, choose Kaiser LA.

3) If something goes wrong at Kaiser, it’s always the residents’ fault

This may not be unique to Kaiser, but this is pretty rampant here. For example, the new policy of increasing ED admitting shifts for residents (mentioned in #1) was implemented because of a possible backup of ED admissions during the winter. However, ask any resident about the rate-limiting step in an ED admission, and that is the attending who reviews all ED admissions. Residents are known to wait 1-2 hours (sometimes even up to 4 hours) to present patients. Sometimes the attendings are so overwhelmed with admissions they get backed up. Sometimes attendings mysteriously disappear during their shifts for hours without responding to pages. Despite trying to present these problems to administration to fix this, the rule is: it’s always the residents’ fault. There’s a backup in ED admissions? Must be the residents’ fault. Solution? Add more shifts!!

Of course, every program is going to have its problems. This is not the worst IM program in LA. HOWEVER, this is not the internal medicine program than many of the residents signed up for. The program needs to be portrayed accurately so that applicants can make well-informed decisions about how they want to spend the next 1 to 3 years of their lives. The truth is that residents are dissatisfied, especially with the rapid changes that have increased call responsibilities over the last 3 years. To put it briefly, senior residents are glad they’re leaving; prelims are relieved it’s only one year; and categorical interns are not looking forward to the next 2.5 years.

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[carreraSCal]

Currently, I am a third-year medicine resident at Kaiser LAMC and want to clarify the remarks made in the above post.

#1
There have been only three so-called "MAJOR" additions to call responsibilities over the past 2.5 years. Further, these were not arbitrary but, in fact, came about as a response to the increased patient volume experienced by all Southern California hospitals due to nearby closures of EDs, the most recent of which was King/Drew.

The changes to the curriculum come from administration but are always discussed with the house staff and voted on by a committee comprised of residents from each PGY level.

The first change implemented was the extension of the long-call end time from 9:00 p.m. to 10:30 p.m., which, on average, occurs every 4th or 5th night during the general medicine ward rotation.

The second change involves the working hours of the day-float intern during 2 weeks of the year. Essentially, the admitting hours of the intern are shifted from 4:00 p.m. to midnight, from the previous time of 7:00 a.m. to 4:00 p.m., to address the higher volume of evening admissions.

Finally, the third change is the winter call, which is a TEMPORARY measure meant to prepare for a possible rise in ED admissions from the anticipated busy flu season. The call involves an additional 1 to 2 NON-OVERNIGHT calls only between December and April. That's right. Let me say that again: the addition of only 1 (maximum 2) non-overnight call for the ENTIRE year.

What has apparently "irked" some residents was the implementation of this policy in the middle of the year. Personally, I agree with most residents in that I do not like to have changes made to my call schedule in the middle of the year. However, any responsible program has to be dynamic and to make adjustments in anticipation of future events such as an H1N1 outbreak.

The flip side of that are programs that do not listen to residents and that stick with the status quo year after year, waiting for enough people to complain before implementing major changes that affect the entire house staff.

The bottom line is that the administration here is open and receptive to the concern of residents. The fact that some of these changes have been unpopular with some residents does not mean they are "deceitful and dishonest."

With regard to the night-float system, it is true that, as an intern, you will be responsible for cross-covering the medicine floors for many patients. However, the overwhelming majority of pages by the nurses will be for constipation orders, sleeping meds, and repletion of potassium.

Yes, you will occasionally encounter patients who may become unstable and require your immediate attention. However, as an intern, you are required to inform your second- or third-year resident in-house for assistance.

I have never encountered a situation during my 2 years in which I felt that I did not have the support of my senior resident or attending during cross-coverage. In addition, there are always 3 attending level house staff in-house solely devoted to the medicine service after hours (admitting, observation, and CCU/tele hospitalist), in addition to fellows taking home call in Card, Pulm, GI, and Nephrology available to answer questions.

Yeah, you might, at times, feel "overwhelmed" on night float, but it is also a period of intense learning during which managing GI bleed, respiratory distress, hypotension, and sepsis becomes second nature.

Overall, although you end up working 27 days of the year on night float, this is spread over 6 weeks of the year, with half of those days being just plain admitting, as opposed to cross-coverage. In return, you look forward to going home and sleeping in your own bed 29 days of the month for ALL other rotations of the year, including general wards, ICU, and CCU.

#2
This is not an isolated incident at Kaiser and, unfortunately, medicine services at every institution get their fair share of so-called "bogus" admissions. But that's the exception, not the rule. Kaiser LAMC is the tertiary referral center for all the Kaiser-affiliated hospitals in the Southern California region, which essentially means that we act a funnel for referrals and transfers of a wide range of medical pathology. I agree that the IM attendings could do a better job of screening admissions. However, the majority of residency programs do not even have an attending present after hours to staff admissions (that's what makes Kaiser unique; see #3); and that means that no screening occurs during call. So it is hardly a problem confined to Kaiser.

#3
Again, the temporary policy of increasing ED admission shifts for residents boils down to this: 1 to 2 NON-OVERNIGHT calls in the span of 4 months in anticipation of an unusually busy flu season.

ALL patients admitted by interns and residents through the ED must be seen and staffed by an attending physician; this is Kaiser's policy to ensure appropriate oversight during a resident call.

To be completely honest, if my loved one were hospitalized, I would want an attending physician to oversee the assessment and plan of the admitting resident. Unfortunately, this is a double-edged sword. On the one hand, it is nice to have an attending present at all times in the ED to screen patients and oversee residents. But, on the other hand, this can cause a backlog during busy nights when multiple residents are waiting to present their admissions.

It is not true, however, that the administration's position is to blame the resident. That is blatantly false. The administration has added a second attending in the ED in response to resident feedback, and this has dramatically reduced waiting times over the past several months.

Finally, I take issue with "lifestyle" being the "major attraction" of residents to this program. Deciding where to go for medicine residency is a personal choice, and I believe that lifestyle is one of many factors that an applicant has to consider. I personally came to Kaiser because I was impressed with the high board pass rate, fellowship opportunities, and job placement, without the malignant clash-of-ego atmosphere associated with other programs.

Any applicant applying to a medicine residency solely on the basis of lifestyle and to avoid "unnecessary stress and work" is in for a big disappointment, regardless of where the applicant ends up.

Residency is demanding and difficult and, undoubtedly, you will have times during which you will feel overworked and underappreciated; that's just the nature of the beast. That having been said, Kaiser is known for the great camaraderie among its house staff. The program is small and most people are on a first-name basis, which fosters a friendly, family-like environment.

As far as resident workload, this is still one of the lightest medicine programs in Southern California, when you take into account total call duration, call frequency, patient load per intern, and total elective and vacation time, despite the "3 MAJOR" changes implemented.

 

[kpsunset]

I am also a current third year resident at Kaiser Permanente (Los Angeles). I concur with the second post entirely, so I won't rediscuss above details. I'm disappointed with the first post, but I know that the overwhelming majority of residents here are very happy. I ranked this program #1, and I continue to be very happy with my choice. I feel very well prepared as an internist, and I am really grateful for all the support and opportunity in pursuing fellowship. With regards to camaraderie, I've never experienced a more friendly academic environment than at this program. I really enjoy coming to work every day because of this. I consider almost all the housestaff and faculty as good friends and/or mentors. I never thought I would say this, but I will really miss residency. I will really miss being a resident in this program. I highly recommend Kaiser Permanente; if you have any questions, please feel free to PM me.