Goodbye to Surgery

[Samoa]

---

Members do not see this ad.

IFNGamma's complaints are valid but they are the complaints of an INTERN...which he probably would have made if he was a MEDICINE INTERN as well (dictating discharge summaries? Those are EASY on Surgery compared to Medicine). Those guys don't have it any easier and I suspect that if he had done a Prelim Medicine year, the post would be identical with just a few names and situations changed.

Exactly. Being an intern sucks, period. Having said that, being a medicine intern would have sucked far worse. I might have been treated a whole lot better on the medicine side of things, but I still would rather be a surgery intern any day.

 

[mosfet]

I agree that a lot of the things he's describing are junior resident-specific, but it's also very likely that him being at a crappy program had a lot to do with his decision.

If I remember correctly, IFN is an IMG, which likely limited his options last March.......

Good luck in your future IFN....At least you made your decision early on.....

 

[Winged Scapula]

Exactly. Being an intern sucks, period. Having said that, being a medicine intern would have sucked far worse. I might have been treated a whole lot better on the medicine side of things, but I still would rather be a surgery intern any day.

Not for someone who clearly wasn't interested in surgery like the OP. Dictating discharge summaries on Surgery would be the easiest part of my day, frankly.

 

[DrDre311]

Not for someone who clearly wasn't interested in surgery like the OP. Dictating discharge summaries on Surgery would be the easiest part of my day, frankly.

Dictating is like a game. I like to see just how fast I can dictate a clinic note or a discharge summary. Sometimes I'll do it in a faux Australian accent or a Borat voice just to see if the transcriptionist can decipher it. My favorite dictation alter ego, though, is Anthony Hopkins as Hannibal Lecter: "Hello, Clarice...this is Dr. Dre dictating a discharge summary on [patient X]...can you hear the lambs crying?"

Sometimes I have to stop dictating because I can't keep from cackling hysterically--but it's fun to dictate a maniacal laugh, too.

 

[Samoa]

I never did find it easy to dictate a discharge summary, mostly because it was a pain in the @ss to sift through the chart for all the required info. But it's definitely better than typing. And rewarding, in that it meant someone was DISCHARGED. Which is always a win.

Edit: I'll have to try that sometime, Dr. Dre. As for me, dictating makes me yawn. Seriously, like every couple of sentences. Sometimes I stop the recording, sometimes I don't.

 

[LovelyRita]

I like surgery. Not everyone can do it. For those of you who can't, don't worry, we'll handle it for ya. 😎

 

[Luv2Cut]

IFNGamma's complaints are valid but they are the complaints of an INTERN...which he probably would have made if he was a MEDICINE INTERN as well (dictating discharge summaries? Those are EASY on Surgery compared to Medicine). Those guys don't have it any easier and I suspect that if he had done a Prelim Medicine year, the post would be identical with just a few names and situations changed.

Good point. Very good point. I remember before starting my intern year the PD speaking to all the residents and was giving advice on what they should be doing at each level, "3rd years you should be thinking about what kind of practice you want to have and where you want to go from here. 2nd years, you should be concentrating on training the interns and become good Senior residents and take more charge in the hospital, you are not interns anymore. Interns...........you should JUST CONCENTRATE ON SURVIVING THE YEAR."

L2C

 

[Winged Scapula]

I never did find it easy to dictate a discharge summary, mostly because it was a pain in the @ss to sift through the chart for all the required info. But it's definitely better than typing. And rewarding, in that it meant someone was DISCHARGED. Which is always a win.

Unless you are off service and don't know the patient at all, what are you going through the chart for to dictate?

Honestly, you don't need to include a day by day detailed discussion of the hospital course. It is sufficient to say:

Mr. X is a 48 year old male who was admitted on June 1, 2008 with a diagnosis of acute pancreatitis. He was treated with intravenous fluids, a restricted diet and serial abdominal examinations were performed. His hospital course was uncomplicated and on the day of discharge his vital signs were stable and within normal limits, his white count and amylase/lipase normal, he was ambulating well without assist, having normal bladder and bowel motions and was tolerating a clear liquid diet without nausea, vomiting or intractable pain. A repeat CT scan showed resolution of peripancreatic inflammation and no evidence of necrosis or pseudocyst. He was discharged to home on HOD # X with follow-up scheduled in Dr. Y's office in 4 weeks.

You should be able to do that in less than a minute and not have to flip through the chart. If someone wants daily labs, vitals, antiobiotics used, etc. they can get that from the chart; you don't need to dictate that.

 

[teddybear]

I hate the Red Sox. Such a damn bandwagon team. I hope they lose every game they play.

They're not a bandwagon team for me, mack daddy. They've been my team my whole life. Even when they did lose every game they played, lol.

 

[Samoa]

Unless you are off service and don't know the patient at all, what are you going through the chart for to dictate?

Honestly, you don't need to include a day by day detailed discussion of the hospital course. It is sufficient to say:

Mr. X is a 48 year old male who was admitted on June 1, 2008 with a diagnosis of acute pancreatitis. He was treated with intravenous fluids, a restricted diet and serial abdominal examinations were performed. His hospital course was uncomplicated and on the day of discharge his vital signs were stable and within normal limits, his white count and amylase/lipase normal, he was ambulating well without assist, having normal bladder and bowel motions and was tolerating a clear liquid diet without nausea, vomiting or intractable pain. A repeat CT scan showed resolution of peripancreatic inflammation and no evidence of necrosis or pseudocyst. He was discharged to home on HOD # X with follow-up scheduled in Dr. Y's office in 4 weeks.

You should be able to do that in less than a minute and not have to flip through the chart. If someone wants daily labs, vitals, antiobiotics used, etc. they can get that from the chart; you don't need to dictate that.

We have to list all the consulting services, all the procedures and the dates, all the diagnoses the patient collected while s/he was there, the HPI, the discharge meds, discharge instructions. It's a lot of stuff I don't keep in my brain from day to day.

You're right, the hospital course is easy, if it's a straightforward case with a straightforward recovery. But many of our patients come on referral, which means they were too complicated for some other surgeon to handle. So most don't have uneventful recoveries. And as we're frequently reminded, our d/c summaries are cc'd to community providers without access to the remainder of the chart. So it has to have enough information to stand pretty much alone.

 

[teddybear]

They're not a bandwagon team for me, mack daddy. They've been my team my whole life. Even when they did lose every game they played, lol.

It's all good though. To each his own.

 

[Strength&Speed]

Unless you are off service and don't know the patient at all, what are you going through the chart for to dictate?

Honestly, you don't need to include a day by day detailed discussion of the hospital course. It is sufficient to say:

Mr. X is a 48 year old male who was admitted on June 1, 2008 with a diagnosis of acute pancreatitis. He was treated with intravenous fluids, a restricted diet and serial abdominal examinations were performed. His hospital course was uncomplicated and on the day of discharge his vital signs were stable and within normal limits, his white count and amylase/lipase normal, he was ambulating well without assist, having normal bladder and bowel motions and was tolerating a clear liquid diet without nausea, vomiting or intractable pain. A repeat CT scan showed resolution of peripancreatic inflammation and no evidence of necrosis or pseudocyst. He was discharged to home on HOD # X with follow-up scheduled in Dr. Y's office in 4 weeks.

You should be able to do that in less than a minute and not have to flip through the chart. If someone wants daily labs, vitals, antiobiotics used, etc. they can get that from the chart; you don't need to dictate that.

You guys are still using Dr. Y? He's crap I tell ya!

 

[teddybear]

Agreed. Weak, unoriginal, and not funny.

The next logical step would have been to intimate that whomever you're trying to insult was into bestiality, dendrophilia, or some combination thereof.

btw I saw 311 in your user name, do you like 311? They ROCK!

 

[Winged Scapula]

You have my sympathies Samoa.

MY attendings (and now me) always dictated letters to the PCP which summarized the diagnosis, treatment and plan; therefore a detailed discharge summary (at least to the extent to you have covered it) was unnecessary.

The post above is very simplistic of course, but even with patients with complicated hospital courses, I'm not sure PCPs need to know (or want to know) daily details of lab work, etc. I understand the reasoning behind detailed discharge summaries, but having seen the extent of paperwork that comes in on a daily basis, I'll bet your PCPs would prefer a shorted dictation of what happened to their patients. After all, does it matter if the patient had serial CT scans if the outcome is improvement (or not)? Do daily labs really add much to the overall picture (exception obviously being labs which support a diagnosis of MI, etc.)?

I receive very lengthy reports from medical and radiation oncologists (dictated by their PAs, BTW) and frankly, only the final paragraph is useful to me. I don't have the time to read all the detailed treatment course...just the highlights please.

 

[DrDre311]

They're not a bandwagon team for me, mack daddy. They've been my team my whole life. Even when they did lose every game they played, lol.

I'm OK with that. What I'm not OK with is bandwagon Red Sox and Cubs fans who come out of the woodwork if and only if the team has a good chance of making the playoffs.

And regardless I hope they lose every game they play.

 

[IFNgamma]

I dunno...I never begged anyone to have me place an NGT, was cursed at, only rarely placed Unna Boots (although its easy, not sure why this is a problem; generally our vascular nurses put them on and off, although I did on occasion when I could do it faster and get the patient out), sacral decubs went to the Plastics residents and certainly didn't see nearly as many EF fistulas as he apparently did.

However, I agree that almost all of us have had the same experience (ie, getting consent for procedures we've never seen or done, getting to work at 0430, etc.). But it appears to me that IFNGamma admits that he did not know enough about surgery and its residency going in before making his decision. Unfortunately, that isn't a rare situation. The problem I have with his posts is his assumption that what he found to be miserable and untolerable is so for everyone and that it means that students should stay away from surgery.

His message that he didn't know enough about surgery and didn't like it enough before starting residency got lost in his message that all surgery internships/residencies suck and no one should pursue one. He is a perfect example of someone who didn't know what he was getting into and ended up choosing the wrong specialty. It happens but that isn't reason for him to assume that the situation will be the same for everyone. In addition, what is describing may very well be program specific.

No one likes the things he's mentioned but for most people who are actually really interested in surgery rather than being concerned with how much time off or call they have, these are the things that we put up with to get to our goals. You cannot tell me that there aren't such things in any field. Believe me, you and I both know, that he will get lame consults for pain management, will eventually have to work on a weekend, and will spent a lot of time talking to families while on ICU rotations.

IFNGamma's complaints are valid but they are the complaints of an INTERN...which he probably would have made if he was a MEDICINE INTERN as well (dictating discharge summaries? Those are EASY on Surgery compared to Medicine). Those guys don't have it any easier and I suspect that if he had done a Prelim Medicine year, the post would be identical with just a few names and situations changed.

you're right, my complaints are of an intern, but even as a 2nd or even 3rd year, I would have to deal w/ the same BS, especially as a 2nd year if the intern was post-call or on vacation.

the reason the d/c summaries suck is that I gotta dictate on pts I never seen before, which the off service residents prior to me didn't bother to which gets dumped on me. Imagine getting a call from med records seeing attending X has a bunch of d/c summaries due so please come and do it, and when u get there u see a huge stack of thick chart.

and yes I didn't know enough about the BS that goes on in surgery outside of being in the OR because I never had the chance to experience it. I chose surgery cuz I love to operate (even now), so I thought I could deal w/ the other BS that goes on, but I was wrong.

 

[core0]

You have my sympathies Samoa.

MY attendings (and now me) always dictated letters to the PCP which summarized the diagnosis, treatment and plan; therefore a detailed discharge summary (at least to the extent to you have covered it) was unnecessary.

The post above is very simplistic of course, but even with patients with complicated hospital courses, I'm not sure PCPs need to know (or want to know) daily details of lab work, etc. I understand the reasoning behind detailed discharge summaries, but having seen the extent of paperwork that comes in on a daily basis, I'll bet your PCPs would prefer a shorted dictation of what happened to their patients. After all, does it matter if the patient had serial CT scans if the outcome is improvement (or not)? Do daily labs really add much to the overall picture (exception obviously being labs which support a diagnosis of MI, etc.)?

I receive very lengthy reports from medical and radiation oncologists (dictated by their PAs, BTW) and frankly, only the final paragraph is useful to me. I don't have the time to read all the detailed treatment course...just the highlights please.

One of the docs I worked for dictated
Assessment
Plan
Everything else

Everything else is just there so that you can bill for a consult. Presumably the referring physician knows a little about the patient and their history. The referring physicians loved it.

Our D/C summaries are similar to WS. Of course since we are going to be following the patient for the rest of their life, the only important part is the med list.

David Carpenter, PA-C

 

[Samoa]

You have my sympathies Samoa.

The post above is very simplistic of course, but even with patients with complicated hospital courses, I'm not sure PCPs need to know (or want to know) daily details of lab work, etc. I understand the reasoning behind detailed discharge summaries, but having seen the extent of paperwork that comes in on a daily basis, I'll bet your PCPs would prefer a shorted dictation of what happened to their patients. After all, does it matter if the patient had serial CT scans if the outcome is improvement (or not)? Do daily labs really add much to the overall picture (exception obviously being labs which support a diagnosis of MI, etc.)?

Agreed, and I'm not talking about details in the hospital course. Dictating lab values and scan results and any discussion of what the patient DIDN'T have is just crazy talk.

But if the patient stayed in house beyond the expected LOS for their primary problem, the discharge summary needs to say why. That's where I draw the line on what to include in the hospital course.

 

[Winged Scapula]

the reason the d/c summaries suck is that I gotta dictate on pts I never seen before, which the off service residents prior to me didn't bother to which gets dumped on me. Imagine getting a call from med records seeing attending X has a bunch of d/c summaries due so please come and do it, and when u get there u see a huge stack of thick chart.

Believe me, I've been there before. We used to have "dictation parties" on Trauma especially where the whole team would go over to medical records and dictate discharge summaries on patients we'd never seen. I used to pray for the charts with the 23 hr obs for closed head injury; those were easy to do. It was the long term SICU players that were painful to dictate.

A good Chief resident would have called up the off service residents and/or their PD and had them come back to finish their work so that you weren't stuck doing it. My rule was no one left service until the summaries were done...so if that meant you stayed until 10 pm on your last day, so be it (Dr. Hartmann is probably still mad at me for that 😉 ).

But I have to say, this behavior and resulting work is not inherent to Surgery. It happens to Medicine residents as well. But you will find Anesthesia much better in terms of this kind of paperwork, although there will still be plenty.

and yes I didn't know enough about the BS that goes on in surgery outside of being in the OR because I never had the chance to experience it. I chose surgery cuz I love to operate (even now), so I thought I could deal w/ the other BS that goes on, but I was wrong.

And that's where it really is so important to be able to see the field; its not all guts and glory in the OR and Trauma Bay. So that others may learn, why didn't you see the peri-operative management during your 3rd and 4th year rotations (you did them in the US, right)? Didn't you have to round on the patients and spend time with the interns seeing all this BS?

I'm glad you found out early that it wasn't for you and hopefully Anesthesia will be all that you hope it to be.

I think others here contemplating Surgery would benefit even more from your warnings if you could detail exactly WHY you didn't get a full picture of the field (as much as you can as a student) and HOW you could have changed that. I could say the same - that I didn't really know what I was getting into (ie, my medical school experience was *much* more benign than my residency) but I found that I could put up with the BS for the operative opportunities and generally figured that BS happened in every field.

 

[Winged Scapula]

Agreed, and I'm not talking about details in the hospital course. Dictating lab values and scan results and any discussion of what the patient DIDN'T have is just crazy talk.

Tell that to the Medicine guys. Tired is right...telling me you worked a patient up for a possible PE but then it turns out to be <just> pneumonia (after several paragraphs) is such a let-down, its like reading a Penthouse Forum story where the guy starts talking about picking up two chix at a Yoga class and have it end with him home alone with his cat.😛

But if the patient stayed in house beyond the expected LOS for their primary problem, the discharge summary needs to say why. That's where I draw the line on what to include in the hospital course.

That's reasonable and probably good practice in this day and age of Insurance Review people trolling your charts for reasons for extended days in house. I guess I just see way too many detailed and lengthy discharge summaries which don't add anything to the knowledge base and are probably largely ignored by the PCPs that you are doing them for.

 

[teddybear]

I'm OK with that. What I'm not OK with is bandwagon Red Sox and Cubs fans who come out of the woodwork if and only if the team has a good chance of making the playoffs.

And regardless I hope they lose every game they play.

Well, I'll concede the bandwagon part. I don't like that type of people either. Shows lack of a backbone.

 

[Luv2Cut]

WS, I love reading your stories, it brings back memories of residency, e.g. ICU players which I always seemed to get.

Tell that to the Medicine guys. Tired is right...telling me you worked a patient up for a possible PE but then it turns out to be <just> pneumonia (after several paragraphs) is such a let-down, its like reading a Penthouse Forum story where the guy starts talking about picking up two chix at a Yoga class and have it end with him home alone with his cat.😛

BTW, I didn't figure you as a big Penthouse reader.


L2C

 

[IFNgamma]

Believe me, I've been there before. We used to have "dictation parties" on Trauma especially where the whole team would go over to medical records and dictate discharge summaries on patients we'd never seen. I used to pray for the charts with the 23 hr obs for closed head injury; those were easy to do. It was the long term SICU players that were painful to dictate.

A good Chief resident would have called up the off service residents and/or their PD and had them come back to finish their work so that you weren't stuck doing it. My rule was no one left service until the summaries were done...so if that meant you stayed until 10 pm on your last day, so be it (Dr. Hartmann is probably still mad at me for that 😉 ).

But I have to say, this behavior and resulting work is not inherent to Surgery. It happens to Medicine residents as well. But you will find Anesthesia much better in terms of this kind of paperwork, although there will still be plenty.



And that's where it really is so important to be able to see the field; its not all guts and glory in the OR and Trauma Bay. So that others may learn, why didn't you see the peri-operative management during your 3rd and 4th year rotations (you did them in the US, right)? Didn't you have to round on the patients and spend time with the interns seeing all this BS?

I'm glad you found out early that it wasn't for you and hopefully Anesthesia will be all that you hope it to be.

I think others here contemplating Surgery would benefit even more from your warnings if you could detail exactly WHY you didn't get a full picture of the field (as much as you can as a student) and HOW you could have changed that. I could say the same - that I didn't really know what I was getting into (ie, my medical school experience was *much* more benign than my residency) but I found that I could put up with the BS for the operative opportunities and generally figured that BS happened in every field.

well, my experience was the same as yours, my experience as a MS was way more benign than residency. I did all my rotations at a small communuity hospital were Surgery was considered by far the best program, and it was not a very busy place, the residents were all great, especially the chiefs. There was a lot of teaching by the residents and attendings because we had plenty of time to do whatever since we were not bogged down by the tremendous amount of consults, floor work at my prior program.

So it was totally different when I got to internship were it was extremely busy with a ton of the BS I mentioned in my 1st post each and everyday.

So I guess I had unrealistic expectations before I started internship. So the lesson here is don't think your experience as a MS will be equivalent what you will experience as a resident.

anyways, the point I want to make is NOT that all surgical residencies are terrible and suck, but to paint a picture of what life as an surgical resident will be like. Be sure you can stand the stuff I mentioned before u go into surgery.

 

[kaos]

Dictating is like a game. I like to see just how fast I can dictate a clinic note or a discharge summary. Sometimes I'll do it in a faux Australian accent or a Borat voice just to see if the transcriptionist can decipher it. My favorite dictation alter ego, though, is Anthony Hopkins as Hannibal Lecter: "Hello, Clarice...this is Dr. Dre dictating a discharge summary on [patient X]...can you hear the lambs crying?"

Sometimes I have to stop dictating because I can't keep from cackling hysterically--but it's fun to dictate a maniacal laugh, too.

Hahaha that's pretty funny!

 

[Winged Scapula]

BTW, I didn't figure you as a big Penthouse reader.

L2C

Anything to keep in touch with what the patients are reading!😀

(I find it amusing more than anything else)

 

[fab4fan]

I hate the Red Sox. Such a damn bandwagon team. I hope they lose every game they play.

Right with you on that. I've hated them even more since they signed on that crybaby Curt Schilling.

 

[Blade28]

Right with you on that. I've hated them even more since they signed on that crybaby Curt Schilling.

Hey! Wait a sec! He's only one of the most clutch postseason pitchers in recent history!

 

[michaelrack]

Believe me, I've been there before. We used to have "dictation parties" on Trauma especially where the whole team would go over to medical records and dictate discharge summaries on patients we'd never seen. I used to pray for the charts with the 23 hr obs for closed head injury; those were easy to do. It was the long term SICU players that were painful to dictate.

When I was a medicine resident, the intern (or resident on some rotations)for the patient at the time of his discharge was responsible for the dictation. Medical records kept track of this and hunted down residents/interns who didn't do their dictations. I believe this was true of most of the speciaties including surgery. The major exception was psychiatry, who operated out of a neighboring hospital with a different medical records system.

 

[Winged Scapula]

When I was a medicine resident, the intern (or resident on some rotations)for the patient at the time of his discharge was responsible for the dictation. Medical records kept track of this and hunted down residents/interns who didn't do their dictations. I believe this was true of most of the speciaties including surgery. The major exception was psychiatry, who operated out of a neighboring hospital with a different medical records system.

I like that idea - medical records tracking down the intern/resident on service at the time of discharge. In our hospital, because we had more than 1 intern and resident on service I could envision a cat/dog fight about who was really responsible.

Most of our problem was with off service residents (ie, EM or Gas doing Trauma) because we couldn't threaten them with taking away their OR time. I was usually a little more forceful than other residents and would actually call the PD of that department to tell them that their residents were not keeping up with their paperwork. That usually did the trick but I felt terrible doing it.

 

[teddybear]

Hey! Wait a sec! He's only one of the most clutch postseason pitchers in recent history!

Thanks.

 

[Pir8DeacDoc]

thankfully we have an electronic medical record and you can start the d/c summary the day the patient is admitted if need be. Plus, cutting and pasting things in there is very helpful/easy. We do have fairly detailed d/c summaries including presenting complaint, procedures, labs, scans, etc. But If you start them early and keep at them a little each day it's not terribly painful. Plus, our patients can't leave our hospital without a signed d/c summary from one of the residents. The attendings can "finalize" the summary later with more details in they so desire. Dictating all that info would be an enormous PITA