Grave concerns about lack of oversight & teaching at new program

[ScalpElectrode]

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Hey Everyone, I'm not entirely sure what to do here.
I'm a new intern and having some serious concerns about my new program.

There's a serious, serious lack of oversight and teaching in my program and I think it may be actually very dangerous for patients.
I was paged to a delivery room earlier this week for delivery (I'm not even on the L&D Service right now, I was just covering triage). No other residents or attendings were there, and none arrived shortly. I had to ask them to page MULTIPLE times before someone finally arrived to assist. There wasn't an emergency happening anywhere else, No Stat- C section or anything. No upper levels to be found, only the one attending it seemed. The attending didn't even fully gown & glove up, but rather just kind of stood to the side and attempted to give instruction.
I very nearly caused a bad outcome because of the poor instruction and the attending couldn't really tell what was going on. He stepped in once he realized what was happening, but I felt like I was really lost. I never should have, as the intern in JULY, had to ask them to page 3-4 times before anyone else showed up. It would have just been me in that room. I felt awful.
I get the impression that they have interns delivering on their own by the middle of the year. I'm not entirely sure this is wise.

Additionally, our clinics are an absolute mess. I'm routinely seeing patients without checking out to anyone, attendings are obviously cosigning notes on patients they've never heard about, etc. I understand this to a degree for routine, noncomplicated patients, but not all of the patients I'm seeing are like this. I've basically been told just to staff things with an upper level and only go find the attending if I really need to. The attending isn't always easily found either, and there's just the one attending for multiple resident clinics.
I'm just the baby intern, and I'm honestly worried I'm going end up making a terrible mistake or really hurt someone.

I expected to feel overwhelmed and stupid in Intern year. I didn't expect that I would be at a university teaching hospital where there's virtually no oversight at all or teaching. I don't know what to do. I feel very lost and genuinely very concerned about the lack of instruction and support I'm getting.
I've tried talking to upper levels about it, they've basically all just kind of said "that's how it is here."

It was not like this at all at my home institution. And this scares me.
Any advice???? If it's this bad and everyone just feels helpless, do I think about transferring?
I know in residency you teach yourself a lot, I expected that, but I'm not sure how I feel about training in a place I genuinely think might be dangerous.

 

[IlDestriero]

Talk with the program director.
Look to change programs for next year.
If instruction sucks at the intern level where they know that you don't know your ass from your elbow, imagine what it is like in later years.

 

[22031 Alum]

Have you talked with your program director??

Your upper levels are very new at their roles and honestly could have spaced out on needing to help you. My program had a few sites, one with much lower OB volume than the rest. As a new third year I once sent my intern to AROM a patient, because at Site #1 or #2 she would have done dozens by that point. But we were at Site #3 and she had never broken a bag before, and was scared to tell me she didn't know how. Not quite delivering alone, but she had no experience assessing how appropriate AROM was and could've easily dropped a cord. That was 100% my mistake.

In a similar vein, every July we'd have to remind the attendings who were only peripherally involved with residents that "Hey, that thing you'd let an intern do alone two weeks ago? You have to scrub for that now."

All that to say, it may be a systemic problem but could've been a mistake. If your program director isn't receptive you may want to look into somewhere else... But I'll warn you. The types of OB programs that tend to have spaces for transfer don't tend to be the places that have excellent instruction. (In general, there are always exceptions.)

 

[Doctor4Life1769]

People forget that it's July.
Remind the attending next time that you are brand new and would like more close assistance.
I can't explain the lack of senior response to the pages, maybe they were away at the cafeteria.

 

[ScalpElectrode]

Have you talked with your program director??

Your upper levels are very new at their roles and honestly could have spaced out on needing to help you. My program had a few sites, one with much lower OB volume than the rest. As a new third year I once sent my intern to AROM a patient, because at Site #1 or #2 she would have done dozens by that point. But we were at Site #3 and she had never broken a bag before, and was scared to tell me she didn't know how. Not quite delivering alone, but she had no experience assessing how appropriate AROM was and could've easily dropped a cord. That was 100% my mistake.

In a similar vein, every July we'd have to remind the attendings who were only peripherally involved with residents that "Hey, that thing you'd let an intern do alone two weeks ago? You have to scrub for that now."

All that to say, it may be a systemic problem but could've been a mistake. If your program director isn't receptive you may want to look into somewhere else... But I'll warn you. The types of OB programs that tend to have spaces for transfer don't tend to be the places that have excellent instruction. (In general, there are always exceptions.)

I've emailed my program director asking to meet with her. Still awaiting a reply. I'm hoping it was a mistake but I strongly get the feeling it's a systemic problem. There's fewer residents on service that day for whatever reason, and the only other thing going on at that time was a scheduled C/S.

 

[Law2Doc]

Hard to know from the post what was going on. Could be, as suggested above, that the attending didn't grasp that a new intern in July and old intern in June aren't operating at the same level. And also there are quite a few med students these days who get pretty good after sub-Is, so sometimes an intern isnt as green as you are describing. But it could also be that the guy was teaching you by immersion. I recall a few attendings who liked to stand at the door and let you take your shot before they gowned up and took over. It's scary at first, but you learn a lot with the training wheels off. I'd talk to seniors and make sure that isn't just the way things work before going to the PD.

 

[ScalpElectrode]

I'm not the only person in my class this has happened to, apparently. One of my co-residents has delivered without anyone else there. She's not happy about it. L&D isn't the only place we aren't getting any guidance, either.

 

[Law2Doc]

... One of my co-residents has delivered without anyone else there. She's not happy about it. ...

I dunno. Seems to me that after you have accomplished this feat once solo, you should actually be pretty happy about it. It only gets to be the first time once. Your co-resident ought to have some swagger now -- "yeah I've done that -- no biggie".

 

[Crayola227]

I dunno. Seems to me that after you have accomplished this feat once solo, you should actually be pretty happy about it. It only gets to be the first time once. Your co-resident ought to have some swagger now -- "yeah I've done that -- no biggie".

This is the most ridiculous thing I have ever heard. This is OB, not gen surg. There's a reason OB has the highest malpractice. No other procedure matters more to patients, period. You can cut the wrong leg off someone and get away with it better than if Baby Timmy doesn't grow up to be President and somehow I think that's the OB's fault. I can't see how an intern should be delivering a baby without anyone above her in the room in the first month. In OB, it's usually a binary outcome, most things go well, but the bad outcomes.... are very bad.

I don't know how things go in OB as far as teaching, like sure, maybe the senior or the attending stands at the door and watches you kill a baby in front of its mother, but at least then the intern has someone to blame.

I'm not in any surgical or OB adjacent field, but I would sooner do an appendectomy with one hand tied behind my back than be a July intern delivering a baby by myself.

 

[pulmoblast]

Summarize your concerns in an email to the program director. You are liable for malpractice even if you are an intern in your first month. Google the Libby Zion case where the first year intern fought in malpractice, criminal and civil court ten+ years after graduation

 

[Law2Doc]

This is the most ridiculous thing I have ever heard. This is OB, not gen surg. There's a reason OB has the highest malpractice. No other procedure matters more to patients, period. You can cut the wrong leg off someone and get away with it better than if Baby Timmy doesn't grow up to be President and somehow I think that's the OB's fault. I can't see how an intern should be delivering a baby without anyone above her in the room in the first month. In OB, it's usually a binary outcome, most things go well, but the bad outcomes.... are very bad.

I don't know how things go in OB as far as teaching, like sure, maybe the senior or the attending stands at the door and watches you kill a baby in front of its mother, but at least then the intern has someone to blame.

I'm not in any surgical or OB adjacent field, but I would sooner do an appendectomy with one hand tied behind my back than be a July intern delivering a baby by myself.

First, the attending in OPs example was there, just not gowned up. Most of us already will have caught several babies with attending supervision as med students during our OB rotations. People actually going into OB usually did sub-I's and away rotations where they caught a whole lot more. So I see nothing wrong with an attending who is present in case something goes bad letting the intern have first crack. At some point it's reasonable for the attending to let the interns fly solo. You may argue that July is not the time, but there's always going to be a first time, whether it be July, August, September, and there's only so much you can learn without actually be the one doing it. This, like any procedure, simply isn't the kind of thing you'll ever get good at by watching someone else do it. you need to gain skill and confidence by doing these things. There's never going to be a time that's not "intern in July" until you've done it.

 

[j4pac]

You have to do what's in the best interest of your patient's. Definitely bring the concerns up to your PD...and keep a record of attempts to address the problem. There is a chance that your attendings don't realize that it is July and you are a new intern who knows practically nothing but to try not to kill your patients.

 

[Crayola227]

I dunno. Seems to me that after you have accomplished this feat once solo, you should actually be pretty happy about it. It only gets to be the first time once. Your co-resident ought to have some swagger now -- "yeah I've done that -- no biggie".

Specifically, the OP said "One of my co-residents has delivered without anyone else there." [emphasis mine]

So Law2Doc, the issue I was responding to was

At some point it's reasonable for the attending to let the interns fly solo.

So I don't think I'm wrong in stating that no matter how many babies an intern caught pre-program, that in the first rotation on L&D that there should at least be an upper in the room during delivery. Especially in a program where OP is reporting that it takes 3-4 pages for an intern to get a hold of anyone during the birth.

Maybe I have a skewed idea, because at my school on L&D almost at the end of the intern's year, while the intern did everything else solo, AROM, dilation checks, whatever, when it came time for catching the baby, a senior showed up. If there was any stitching, the senior would take a look and if it was easy might take off while the intern finished that up on their own. The attending would pop in the door and eyeball things usually. If no one was in the room, uppers were around the small floor and it was easy to send the nurse to track down a senior from somewhere and grab them to get them in the room for the delivery.

I could see taking the attending out of the equation, but in July it seems like a upper level resident should at least be handy. Intern should not be doing a completely solo catch on the first L&D rotation.

I don't know, I've never been anywhere that I've seen this level of lack of supervision, not even in an East Coast big city slum hospital in a busy ED service, doing things not even as a big of a deal as delivery. I've done a lot of ED rotations where an upper at least throws eyes on every cut sutured.

 

[Law2Doc]

Specifically, the OP said "One of my co-residents has delivered without anyone else there." [emphasis mine]

So Law2Doc, the issue I was responding to was


So I don't think I'm wrong in stating that no matter how many babies an intern caught pre-program, that in the first rotation on L&D that there should at least be an upper in the room during delivery. Especially in a program where OP is reporting that it takes 3-4 pages for an intern to get a hold of anyone during the birth.

Maybe I have a skewed idea, because at my school on L&D almost at the end of the intern's year, while the intern did everything else solo, AROM, dilation checks, whatever, when it came time for catching the baby, a senior showed up. If there was any stitching, the senior would take a look and if it was easy might take off while the intern finished that up on their own. The attending would pop in the door and eyeball things usually. If no one was in the room, uppers were around the small floor and it was easy to send the nurse to track down a senior from somewhere and grab them to get them in the room for the delivery.

I could see taking the attending out of the equation, but in July it seems like a upper level resident should at least be handy. Intern should not be doing a completely solo catch on the first L&D rotation.

I don't know, I've never been anywhere that I've seen this level of lack of supervision, not even in an East Coast big city slum hospital in a busy ED service, doing things not even as a big of a deal as delivery. I've done a lot of ED rotations where an upper at least throws eyes on every cut sutured.

I've seen programs where seniors micromanaged interns and I've seen programs where interns were allowed to push the envelope. The latter is probably better for learning while the former is perhaps better for the patient. There will always be a point where the training wheels have to come off though. I'm not sure an intern who has never done something unsupervised is ever going to not be a "July intern" though. Procedural medicine is something you learn by doing. Best interest of the patient, though important, can't be used as an impediment to training. Someone more senior can always do a procedure better than someone more junior until that junior has a few under his belt. Our apprentice system allows for attendings to give juniors a somewhat long leash so they can learn. There isn't a set timing for when an intern should do what, but the sooner people get their hands dirty the sooner they become more autonomous.

 

[22031 Alum]

I've seen programs where seniors micromanaged interns and I've seen programs where interns were allowed to push the envelope. The latter is probably better for learning while the former is perhaps better for the patient. There will always be a point where the training wheels have to come off though. I'm not sure an intern who has never done something unsupervised is ever going to not be a "July intern" though. Procedural medicine is something you learn by doing. Best interest of the patient, though important, can't be used as an impediment to training. Someone more senior can always do a procedure better than someone more junior until that junior has a few under his belt. Our apprentice system allows for attendings to give juniors a somewhat long leash so they can learn. There isn't a set timing for when an intern should do what, but the sooner people get their hands dirty the sooner they become more autonomous.

You're arguing the wrong point. I don't think anybody is saying that interns should never deliver solo. But delivering completely unsupervised (nobody else in the room) is not the norm for an intern in July, if not the entire year. Somebody more senior being present is not an impediment to learning as you seem to be implying. Even if that person chooses to be completely hands-off (which I do often), the supervision is key.

 

[Crayola227]

I agree with Law2Doc's reasoning about leashes and learning, and procedural training, but I think 22031 at the baby factory hits the nail on the head.

Yes, there is something psychologically different about doing the exact same thing with no one watching you vs watching you, like theater rehearsal vs in front of a live audience. At some point, yes, you need to do things with no safety net whatsoever. And internship is a sink or swim process, it's not like learning to crawl before you learn to walk. In hindsight I can see why it was impossible to stepwise my way from MS4 to my first day as an intern.

But let's not forget, that patient safety is supposedly the most important thing. I would rather train for 2mos with no loss of life and limb, than train for 1 mo and maim someone, the cost of my increased speed of learning should not be using patients as speed bumps in my path of learning. And I don't say that lightly because every day of residency is a long painful one.

The patients are my guinea pigs and they do at times suffer for the sake of my learning, and there's no avoiding that to some extent. I don't take that lightly either. And whoever is supposed to be supervising shouldn't either.

I just can't imagine that whatever negative learning affect of having a pair of more experienced eyes on me isn't massively offset by patient safety. And maybe I learn and perform better when I'm less scared I'm going to inadvertently hurt someone. So maybe the net effect of those eyes is more patient safety and more learning. I think this is essentially the rationale behind what are the current standards of resident supervision.

Yes, I know, the stupid fantasy pipe dream of having more docs, more time. More teamwork, more teaching, more training.

 

[Crayola227]

Back to OP:

Yeah, it never occurred to me that maybe there's a confusion lag-time for everyone to adjust to the new roles the July changing of the guard brings. Even the attendings that do this every July, well, every July is only once a year. Everything is new even for the people who have been there, because a bunch of people left and a bunch of people just showed up, and the people in the middle are adjusting to new jobs. It's not funny but every hospital with a residency program can chart medical errors/morbidity/mortality jumps right in June/July. Worst time of year to be a patient at a hospital with house officers.
At the start of the year there's always problems with paging people, always. There's always a little dance between resident and attending to figure out the leash length. That attending for whatever reason started out with a trust that he could stand at the door, and learned through trial and error with you to gown and glove. That may have woken him up to do that with all the new interns now, or just with you for a bit until he figures out when you know enough for him to go back to standing at the door.

I don't know that I would talk to the PD or Chief. I've learned that I don't want them to know who I am. I do not want their attention. Usually a PD or a Chief interacts with a resident for 1 of the following reasons:
1) You have a problem that needs solving and have brought it to them. That means they now have 1 more problem to solve. You may not be the problem, but you are its messenger. And messengers get killed. "Thank you for bringing this to my attention." Really? Sure, maybe you've done a great service to all. Actually though, if the problem that you have brought is a problem that is a system problem, one that your seniors have indicated is a well known problem that everyone else is silently dealing with, then it's not a secret, and all you've done now is to tell the PD that you're the one who has the problem with the problem, which might put you into the next category:
2) You are the problem that needs solving.
Now, yes, you want to be proactive about problems, and sometimes it's better to show up at the PD's door than to be called in to it, but I would only walk up to door number 1 and door number 2 above and knock if I thought I was going to be forced that way anyway.

If you can meet secretly with like an omsbudsmen, and you know that's secret, that could be OK.
Maybe if you can figure out a way (and it cannot be from a work email or written in your scrawl) to communicate anonymously in a very professional, non-whiny way your concerns, the Program may be forced to address it or pay lip service to it.

Being proactive would be to tell whoever is in charge of you that day (there's always someone, even if it's just in theory and you see them for a minute) what you feel unsure about and what help you think you might need, or if you don't know that, what help might they suggest? You could say, "I really don't want to be the only one gowned and gloved for any delivery today if we can avoid it. What can I do?" It took me a while to even figure out who were the attendings we were working with, and I never imagined going to them and saying, "I'm an intern, and I think I need some extra help with ____" until that occurred to me, and I don't know when that was.

As far as malpractice concerns, I'm not an expert, but documentation is a huge line of defense, and if you do send that letter anonymously, you can still send it certified and keep a copy, to show that you made your concerns known to the program even if you were nameless... meaning, that you have proof you had a concern about supervision and proof that concern was passed along. Pages can actually be tracked as well, so always call/page someone above you because if they are aware of a situation and it goes south, they are going with you. I learned this from Perrotfish. Perrotfish is wise and you should read what they post.

Call often. If only to spread the blame around. If you can do nothing else sign out your management to the senior every 2-3 hours. Set an alarm in your phone so that you always do it. It can take 5 minutes to run the list, and once the Senior knows about your management he's at least on the line for it with you.

That quote was for covering too many patients on nightfloat, but surely working triage there must be someone you can bug/pass blame to.

I have a couple of other pieces of advice for you:

When it comes to residency, you need to do everything in your power to make it work where you are. It sucks wherever you are, but looking for an out is a fantasy. You have no idea if you will be able to land anywhere better, and just attempting to transfer may hurt you where you are, or if you are successful may hurt you wherever you go. Where you are will wonder why you want to bail, and where you go will want to know why you bailed. Sure, you think because whatever program you transferred to took you they must feel good about you. Not necessarily so. They will take you because they're looking to solve whatever problem it is they have, and the fact that you are its solution has not much to do with how they feel about you, but they will be eyeing you. "If a guy cheats on his wife and leaves her to be with you, don't you always have to wonder if he'll do the same to you?" They will wonder if the problem was really that the other program was too unreasonable to adjust to, or if you're just not adjustable enough (I'm not assuming here that the hypothetical program you're transferring to has good insight into the other program or its reputation, who knows?)

You also don't know enough right now to gauge if things really are as bad as you think they are, and by the time you do or by the time you arrange a transfer, bad program or good, it may be immaterial because at that point you may have adjusted to where you are.

As far as making good with where you are, I feel like every intern feels scared and like they're not getting enough help because you just don't have enough experience or confidence. What's weirder, sometimes you're getting more supervision than you think you are getting because of chart stalking. There were times I was freaking out searching for someone above me like "Christ, have they seen this patient? Do they know how f*cked they are? I put in orders, I have no idea if I did the right thing." and paging, calling, running around trying to find someone above me, only to have the attending get back to me 3 hrs later because he had seen the patient, looked at what I did, and moved on. Everything was fine, and in medicine, no news is good news. But that sounds the same and feels the same to an intern as the time a patient is dying on me and I'm paging Jesus Mary and Joseph about it and only the Angel of Death shows up in the meantime.

Taken from another post of mine (because it relates to the idea of waving a white flag and making sure the people you're working with understand)
I like other docs to know up front that I'm an intern, that way they know why I sound dumb. I noticed the consultants were a lot nicer to me once I lowered their expectations. You only have the target on your back / shield of being an intern once, might as well use that to what little advantage it offers, namely the only advantage which is lowering expectations. Sometimes you're taken less seriously/discounted/talked down to as a result, but I'd rather that then have any misunderstandings about how much weight I have on the team, and at the end of the day, if they think less of me for being an intern, have at it. Human punching bag at your service if that makes you feel better about your day oh mighty one above me in the hierarchy.

 

[Crayola227]

There will be bad outcomes directly attributable to resident, attending, system error. You will know in your heart of hearts: that if something you or someone else had either done or not done, that should have been done or not done, that someone f*cked up, should have known it, should have avoided it, and that as a result someone died. Most of the time that is avoided, but it will happen. More than once. Make peace with it. Sometimes it will be your fault, sometimes it will be someone else's. Just pray when it is your fault that it is easy to overlook/cover-up and that you have curried enough favor for others to look the other way.

Do as you're told, do it as well as you can, speak up if you really have a bad feeling, and just be sure that when the above **** storm happens you've dotted i's t's documented, called, paged, and then fully engage in the ensuing conspiracy cover up, that it will be a CYCA (cover your collective asses)

Sounds brutal, I don't want patients to be the speed bumps on my path out of residency, but you must engage in the system as wholeheartedly as you can, because if you don't hurt patients now, you will not be able to help any later, and you can forgive yourself for this because you didn't make the system and you can't fight it either. You can't make an omelette without cracking a few eggs. Or babies.

 

[drkristy85]

I've seen programs where seniors micromanaged interns and I've seen programs where interns were allowed to push the envelope. The latter is probably better for learning while the former is perhaps better for the patient. There will always be a point where the training wheels have to come off though. I'm not sure an intern who has never done something unsupervised is ever going to not be a "July intern" though. Procedural medicine is something you learn by doing. Best interest of the patient, though important, can't be used as an impediment to training. Someone more senior can always do a procedure better than someone more junior until that junior has a few under his belt. Our apprentice system allows for attendings to give juniors a somewhat long leash so they can learn. There isn't a set timing for when an intern should do what, but the sooner people get their hands dirty the sooner they become more autonomous.

Completely agree with this. We have the opposite problem of the OP at my pediatric residency program. The training wheels never come off, not even in your last PGY-3 year. The attendings don't give us any autonomy and always make decisions for us. We never get to do procedures on our own. Often times, we are not even allowed to do procedures at all, but have to just watch the attendings do the procedures. It leads to big issues in that the attendings who graduated from our program and work there now as attendings are still green. Many of them seem to constantly need help from specialists on very simple cases. It has been brought up multiple times to our Program Director as well as faculty. They hold a meeting where they remind us that patients always come first. That way, when we graduate, we won't know what we are doing so we will kill people then :0

 

[jl lin]

Yikes. Scary place in which to be new and not have proper guidance. What the OP presents is not a time for training wheels to come off--especially when you can barely hold the bike up. Too many things can go wrong. I would have to express my concerns. It's the how that may be tricky, depending on the politics. Just my off-to-the-side POV.

And the imbalance--one extreme--OP's situation, compared to drkristy85, well neither is very good. My argument in the HC disciplines is the strong need for fairly objective systems of evaluation and the use of sound prognostic indicators. This means more time teaching, leading, and doing timely, objective systems of evaluations at regular intervals--as opposed to seeing folks as cheap labor. I know that isn't always the case, just saying. ..

 

[Law2Doc]

You're arguing the wrong point. I don't think anybody is saying that interns should never deliver solo. But delivering completely unsupervised (nobody else in the room) is not the norm for an intern in July, if not the entire year. Somebody more senior being present is not an impediment to learning as you seem to be implying. Even if that person chooses to be completely hands-off (which I do often), the supervision is key.

The only thing you really disagree with me on is the timing, and the length of the leash (the attending looking on vs at the doorway vs available if someone shouts for them, etc), but I'm not sure you have much basis for when other than that early is "not the norm." truth of the matter is most of these time frames of when you should be doing what are pretty arbitrary rather than empirically derived. One program might see another as coddling it's trainees more than necessary. And a competent intern might be able to do some things sooner, a less competent intern might still struggle later no matter when you set the threshold. But you can't really argue that the intern that has a few under his/her belt isn't further along in the training.

We see this dichotomy in a lot of specialties when you compare interns in academic training programs versus community settings. The community doctors tend to be better technicians coming out of residency because they do more sooner. But they often have less foundation in terms of zebras, have managed fewer rocks with multiple comorbidities on the floor, etc. I'm not sure I could say which is better in the end, but I do know that at some point the training wheels have to come off and for some sooner is going to help them get more competent and confident faster.

The biggest hurdle for residents in residency is getting to the point where you realize you are the doctor not the student/assistant. Being alone at night helps this. Doing things solo helps this. I'm not sure there's good evidence of who should be doing what when but it's not such a compelling argument to say "its really not the norm" (unless you are suggesting it to a jury as the standard of care. But that's a slippery slope argument that would kill residency training as we know it -- counsel could always say "an attending should be doing this" at this stage).

 

[jl lin]

The biggest hurdle for residents in residency is getting to the point where you realize you are the doctor not the student/assistant. Being alone at night helps this. Doing things solo helps this. I'm not sure there's good evidence of who should be doing what when but it's not such a compelling argument to say "its really not the norm" (unless you are suggesting it to a jury as the standard of care. But that's a slippery slope argument that would kill residency training as we know it -- counsel could always say "an attending should be doing this" at this stage).

Honest question...you raise an interesting point. Would you mind expanding on it just a bit more?

 

[Siggy]

Honest question...you raise an interesting point. Would you mind expanding on it just a bit more?

I'm going to guess, "if you're in front of a jury than someone "screwed up" and apparently the resident wasn't actually ready for that much leash."

 

[Crayola227]

The only thing you really disagree with me on is the timing, and the length of the leash (the attending looking on vs at the doorway vs available if someone shouts for them, etc), but I'm not sure you have much basis for when other than that early is "not the norm." truth of the matter is most of these time frames of when you should be doing what are pretty arbitrary rather than empirically derived. One program might see another as coddling it's trainees more than necessary. And a competent intern might be able to do some things sooner, a less competent intern might still struggle later no matter when you set the threshold. But you can't really argue that the intern that has a few under his/her belt isn't further along in the training.

We see this dichotomy in a lot of specialties when you compare interns in academic training programs versus community settings. The community doctors tend to be better technicians coming out of residency because they do more sooner. But they often have less foundation in terms of zebras, have managed fewer rocks with multiple comorbidities on the floor, etc. I'm not sure I could say which is better in the end, but I do know that at some point the training wheels have to come off and for some sooner is going to help them get more competent and confident faster.

The biggest hurdle for residents in residency is getting to the point where you realize you are the doctor not the student/assistant. Being alone at night helps this. Doing things solo helps this. I'm not sure there's good evidence of who should be doing what when but it's not such a compelling argument to say "its really not the norm" (unless you are suggesting it to a jury as the standard of care. But that's a slippery slope argument that would kill residency training as we know it -- counsel could always say "an attending should be doing this" at this stage).

Yeah, you do raise good points.

There's a difference to me practicing my judgement in the vacuum of my brain (someone could make a joke there, but think of a plan, intern, think!) and then looking for approval and getting it rubber stamped right away. That gives me security in my judgement and confidence, and I'll keep on, but that IS psychologically different than actually facing my fear of being wrong (to the patient, not the attending) and having to actually rely on my judgement. The transition must be made at some point.

Yes, the solution isn't to say "someone more experienced should do this," that's impractical and that's why residencies exist even though it's sort of a horrifying process to all, it's necessary. At least until we learn to take attending brains and preserve them in glass jars and transfer them to new bodies, but one argues we might still need new types of minds to cope with innovations always being made in medicine.

That being said, if I know enough to know I don't know of trust my judgement yet, for the sake of the patient, my psyche, and malpractice, it isn't unreasonable to say that an upper or an attending should be somewhat handy in July for a delivery. An upper or attending should always be somewhat handy, even if they're hands off. Residency to me feels a lot like whatever that game was with lifelines. Trying to sit in the hot seat and not use them, but you really need them sometimes and you gotta have them.

And yeah, so many of my colleagues b*tch there's not much learning on nightfloat, and I think that's a crock. Writing ambien orders isn't the most educational, but that's the price of learning to triage and manage a large number of patients you don't know. That teaches you to be efficient in chart review and thought, learn to prioritize problems, deal with acute problems, and get a good sense of what a fire really smells like, and you do have to reach more and take more responsibility and fly solo. Not being bogged down with typing a whole bunch of f*ing notes and micromanaging every problem on the problem list and all the nuts and bolts that happen in days, not spending your time with teaching rounds, more of the learning is less didactic and more about really taking ownership of what feels like scary decisions, and that doesn't happen in days. It can feel like you're not thinking and just throwing orders out there, but you are thinking you're just not watching yourself think and hemming and hawing for a while because there isn't time. I felt like Paul in Dune, "I must face my fear..." I thought there was a lot of growth in myself and my colleagues after doing nightfloat. The nightfloat haters can suck it.

 

[22031 Alum]

The only thing you really disagree with me on is the timing, and the length of the leash (the attending looking on vs at the doorway vs available if someone shouts for them, etc), but I'm not sure you have much basis for when other than that early is "not the norm." truth of the matter is most of these time frames of when you should be doing what are pretty arbitrary rather than empirically derived.

I still think we're talking across each other. You're making sweeping statements about resident autonomy in general, when I (and I think everybody else) is responding to this particular overwhelmed intern's specific situation. You can't honestly think it's okay for an intern at this point to feel like she's gotten no instruction and supervision yet. If you do, we'll just have to agree to disagree. Maybe it's my specialty bias talking. Can interns deliver solo? Sure. Do programs differ on when that happens? Of course. Is it okay to let them do so from the start, without even observing them once to see if that's something they're capable of doing (by either skill or comfort level)? Never. That's how I interpreted OP's complaint. If I'm in charge of training someone, I have to see how long the leash can be before I just let them loose on it. If I just assume capability with no empiric evidence, that's how I end up getting called in the middle of a terrible situation (and served up to 18 years later).

PS- you mentioned that OB interns should have delivered as sub-Is. Many, many prospective residents do gyn or gyn subspecialty sub-I's and could legitimately come to internship having never delivered anything but a placenta.

 

[Crayola227]

Right, so how do we give advice to actually help OP figure out how to function in this system and get the help they need? Oy vey.

I essentially told them to look to their seniors, and it sounds like they did, and they were told to suck it up. Well, try to figure out exactly what help you need and bug them again. Fight for their help (nicely). Yeah, you may have to go higher to get help. Try to help yourself first, try to get help from whoever's right above you first, and work your way up, go to the Program director as a last resort I say. They're going to a lot more sympathetic if you can show a trail of things you've tried to do to get the help you need. Tread carefully. Document. Document what you've done to get help and the response. Keep that to yourself for now. When you ask for help, try not to sound whiney, try not to make it sound like you're pointing fingers or finding fault, try to be nice about it. If you do make it the the Program Director, this is going to come across a lot better if you have a lot to show for yourself that was taking responsibility for yourself in the system and that the string of things you've done is what has finally brought them to their door. And then, I hate to tell you this, suck it up and keep going. You could consider a transfer. At the end of the day, if you want to be a doctor you're going to have to make a lot of compromises and some of those may be safety and to your integrity in the course of your training. So do your best even if you know that's just not good enough, transfer, or quit. That's all there is to it I'm afraid.

 

[Crayola227]

Ah, but don't despair. After a few terrifying moments you may come to find it wasn't all that bad and it's actually much more manageable than you thought it was, and the uppers knew that which is why they let you stew in your own terror. Keep showing up to work, do your best, cross your fingers, try to make friends. It gets better, even when someone dies, you're sued, you're fired, you quit. You're able-bodied with an MD. Even if all those things above happen, it actually is not the worst thing that could ever happen long as you keep surviving, try to keep friends, family, enough heart & health to enjoy them, your life will work out. This is from someone who stepped back from a ledge. You're in residency, it's not that bad yet. You can do this, you can. Godspeed.

 

[Law2Doc]

... You can't honestly think it's okay for an intern at this point to feel like she's gotten no instruction and supervision yet...

I'm saying that doing something on your own without supervision at some earlier point (it doesn't have to be July, but soon after) is simply going to be much more effective training than watching a dozen, and then doing another dozen with the attending over your shoulder before you ever get to fly solo. Yes that's safer for the patient, and yes the intern is going to feel overwhelmed, but so what. The biggest hurdle in medical training isn't ever technique or knowledge IMHO, it's not seeing yourself as "the doctor" rather than some doctors assistant ( this is true in every medical field). That's when you start to actually learn because the buck starts with you. That's why you need to take call by yourself at the earliest point, need to do lots of procedures solo, and be at risk of naming mistakes. Until you do that you won't every be more than a "July intern".

 

[Crayola227]

I can't help but think of the pilot episode of Scrubs where Turk takes the needle from JD and say, "Learn by doing, learn by doing" and shoves it in this lady.

 

[Crayola227]

Yes, so what if the patient is safer and it takes longer to train the intern to a certain point? Better to train faster.! Patient safety and definitely intern comfort be DAMNED!

 

[Crayola227]

Maybe for some us of the big hurdle is knowledge and technique. And if that were the case, more important for the attending than the patient (totally sarcastic there) that that were recognized. and that if that were so, or even if the intern thought that were so, that it was a matter of knowledge and technique, better an upper come when I call.

"They" are always telling us the importance of us know our limits and knowing when to call. For f*cks sake, attendings have to call for help in the form of consults. I'm always hearing some story of the bigshot doc that didn't recognize they couldn't do it on their own, didn't get a consult when they should've, and OOPS there goes heart or kidneys or whatever expendable body part.

 

[jl lin]

I'm going to guess, "if you're in front of a jury than someone "screwed up" and apparently the resident wasn't actually ready for that much leash."

I get that, but what is wrong w/ incorporating sound SOC in the learning process? If there are progressive and sound objective clinical analyses (as much as can be--and no, in general, we are not there yet in most places in terms of clinical learning), part of the use of sound SOP in clinical learning would be, indeed, the 911 to the more senior resident, fellow, or attending when a resident sees that he is in over her/his head. Even attendings have to know when they are, for whatever reason, in over their head. The weird exception would be the person practicing someone out in East Jabip. Besides, each case would be evaluated on its own merit, so. . .

 

[22031 Alum]

I'm saying that doing something on your own without supervision at some earlier point (it doesn't have to be July, but soon after) is simply going to be much more effective training than watching a dozen, and then doing another dozen with the attending over your shoulder before you ever get to fly solo. Yes that's safer for the patient, and yes the intern is going to feel overwhelmed, but so what. The biggest hurdle in medical training isn't ever technique or knowledge IMHO, it's not seeing yourself as "the doctor" rather than some doctors assistant ( this is true in every medical field). That's when you start to actually learn because the buck starts with you. That's why you need to take call by yourself at the earliest point, need to do lots of procedures solo, and be at risk of naming mistakes. Until you do that you won't every be more than a "July intern".

Bold is where we differ. I thought you were in a surgical field, but I'll willingly acknowledge that even if you are, OB is just different -- even compared to Gyn surgery. The level of acceptable risk of making mistakes is simply different. My residents can see themselves as "THE doctor" and take absolute ownership of the patients all they want, but if their delivery technique sucks they could kill a baby. That's not hyperbole, and it's not in the same way as a peds resident ordering the wrong med- we're talking no checks besides a supervisory presence, with a very, very short time to act. If they're flying solo before their technique is sound, some small thing that they'd get away with doing wrong 99 times, can on the 100th time yield a dead baby in the time it'd take me to run down the hall. Or a severely compromised baby in the time it takes me to throw on gloves (no gown in such situations). So I'm going to keep making sure they clear the technique hurdle first and foremost, then worry about the "I'm the doctor" hurdle later. Once I've verified their capability, technique-wise, then the leash lengthens.

Now in the gyn OR, flying solo happens much faster. Different consequences for mistakes.

 

[jl lin]

I'm saying that doing something on your own without supervision at some earlier point (it doesn't have to be July, but soon after) is simply going to be much more effective training than watching a dozen, and then doing another dozen with the attending over your shoulder before you ever get to fly solo. Yes that's safer for the patient, and yes the intern is going to feel overwhelmed, but so what. The biggest hurdle in medical training isn't ever technique or knowledge IMHO, it's not seeing yourself as "the doctor" rather than some doctors assistant ( this is true in every medical field). That's when you start to actually learn because the buck starts with you. That's why you need to take call by yourself at the earliest point, need to do lots of procedures solo, and be at risk of naming mistakes. Until you do that you won't every be more than a "July intern".

Again, this is an honest questioning on my part, but advocating for the patient first and foremost and maintaining SOP has to matter and come first.

I mean I like what Crayola ha shared to some degree, but sucking it up is a lot different to me at least, than not putting the safety of the patients first. No one here was there with the OP to know exactly how problematic things became; but regardless, the patient has to come first and it would seem quite clear that this early on was too early to send someone into a problematic situation to 'fake it till you make it.'

As I said, some of this can be remedied by having programs whereby prognostic indicators and more objective systems of evaluation are put in place. That's a whole lot of time and aggravation for a problem; but it a lot better for both the patients and the residents. When people are learning, they gain competence by knowing where they stand. I get frustrated when in clinical experienced there is just a lack of real investment in how to teach, guide, direct, mentor, and mature the adult learner. But I can see why you didn't respond to me--even though I am not in the midst of it yet from a physician perspective.

So basically what I have seen in other HC clinical learning is not too different than in medicine, clinical learning. And I am not gonna lie. It's a little disturbing to me.

 

[jl lin]

Bold is where we differ. I thought you were in a surgical field, but I'll willingly acknowledge that even if you are, OB is just different -- even compared to Gyn surgery. The level of acceptable risk of making mistakes is simply different. My residents can see themselves as "THE doctor" and take absolute ownership of the patients all they want, but if their delivery technique sucks they could kill a baby. That's not hyperbole, and it's not in the same way as a peds resident ordering the wrong med- we're talking no checks besides a supervisory presence, with a very, very short time to act. If they're flying solo before their technique is sound, some small thing that they'd get away with doing wrong 99 times, can on the 100th time yield a dead baby in the time it'd take me to run down the hall. Or a severely compromised baby in the time it takes me to throw on gloves (no gown in such situations). So I'm going to keep making sure they clear the technique hurdle first and foremost, then worry about the "I'm the doctor" hurdle later. Once I've verified their capability, technique-wise, then the leash lengthens.

Now in the gyn OR, flying solo happens much faster. Different consequences for mistakes.

Yes. That is what I would hope to see. Some internal stress somewhat relieved. TY.

 

[Law2Doc]

... Once I've verified their capability, technique-wise, then the leash lengthens...

Again though you keep going back to your OWN opinion of when someone is ready, or what the norm is (or should be) in your own opinion. Nothing empiric here. That's really relevant only to where you work and you shouldn't be trying to extrapolate it elsewhere. If some other attending thinks his interns are more capable in July than you give them credit, and that they really need to learn by doing, I'm not sure why your view automatically trumps here. And that's kind of my point. You might be totally correct in how to train an intern OR you may be the reason interns at your hospital still aren't functioning as autonomously in September as they could be. But taking the black and white view that view that your approach is the norm or the only appropriate one, or that OB is just different, etc makes your position pretty indefensible. It's basically you saying "Sorry Captain Magellan the world is flat and your voyage will be futile."... Except when it turns out it's not.

To a fair extent I'm playing devils advocate in arguing the extreme here, but I again think you are overestimating the value of "seeing" and underestimating the value of learning by "doing." I know I and many others who actually learned relatively little doctoring until the training wheels came off and we had to handle things on our own. It's very easy to zone out and be on auto-pilot when you know you are working with a huge safety net. By actually being "the doctor" at the earliest possible point, not just an underling who doesn't have to make the hard calls, you get trained, build confidence and gain experience making decisions. And youll NEVER be ready for that until you do it once. For many it doesnt really matter how long you make the leash, because as long as the leash is there, you aren't going to get the same patient ownership. I'm not saying it has to be July, but I'm betting it doesn't have to be as late as whatever arbitrary time you think is the "norm" either.

 

[Law2Doc]

I get that, but what is wrong w/ incorporating sound SOC in the learning process? If there are progressive and sound objective clinical analyses (as much as can be--and no, in general, we are not there yet in most places in terms of clinical learning), part of the use of sound SOP in clinical learning would be, indeed, the 911 to the more senior resident, fellow, or attending when a resident sees that he is in over her/his head. Even attendings have to know when they are, for whatever reason, in over their head. The weird exception would be the person practicing someone out in East Jabip. Besides, each case would be evaluated on its own merit, so. . .

SOC is both a sword and shield. In medicine you probably want as few bright line rules as possible because you need to be able to exercise good clinical judgment under the circumstances without an expert saying you went afoul of some accepted norm. In education especially you don't want to incorporate standard of care concepts because not every trainee blossoms at the same pace and what is reasonable for some may be too high or low a threshold for others. I think patient safety is certainly important, but frankly something that has to be not the sole objective or useful training can never happen. If you want good doctors you have to let them learn by doing, even sometime learning from their mistakes. The myth in this thread to some extent is that with an attending standing by their side they will learn as effectively as if they go it along and make blunders. There's not a doctor out there who hasn't made a mistake and learned from it, and those lessons stick with you more than nothing you'll ever learn in a Classroom. I'm not saying errors should be the goal, but creating a lockstep system of expectations centered on protecting the patient rather than our teaching hopital apprentice system of giving the future doctor the freedom to learn by doing is probably a bad idea and will just mean more doctors are still making rookie mistakes years after they should be rookies.

 

[22031 Alum]

We're still talking past each other. I was never trying to comment on residency training in general. Just how this particular intern feeling undersupervised may be inappropriate for the particular procedure that was being done. Extrapolating to imply that I mean residents in general should never "learn by doing" until some arbitrary time, thus crippling them as physicians in training, is stretching the argument past any point made in this thread (at least by me). I don't think any attending here would argue that the training wheels don't need to come off at some point. Nor would any of us argue that there is both a "too late" and a "too soon" for this to happen, or that it differs based on who you ask. So I have to be honest, your purpose in constantly repeating that it has to happen at some point is lost on me, because I don't actually disagree with you.

 

[Crayola227]

We're still talking past each other. I was never trying to comment on residency training in general. Just how this particular intern feeling undersupervised may be inappropriate for the particular procedure that was being done. Extrapolating to imply that I mean residents in general should never "learn by doing" until some arbitrary time, thus crippling them as physicians in training, is stretching the argument past any point made in this thread (at least by me). I don't think any attending here would argue that the training wheels don't need to come off at some point. Nor would any of us argue that there is both a "too late" and a "too soon" for this to happen, or that it differs based on who you ask. So I have to be honest, your purpose in constantly repeating that it has to happen at some point is lost on me, because I don't actually disagree with you.

I'm gonna have to give it to the doc at the baby factory as far as how baby delivering should be supervised.

 

[ScalpElectrode]

Honestly, I would like to thank everyone for the replies and advice here. I did end up talking with my PD and it was brought up at a staff meeting and things seem to have improved a bit. OB is different from other fields though in the sense that things can go very wrong, very quickly, and I appreciate that people have brought that up. I am not someone who needs to have her hand held through everything for an entire year, but I am an intern in July doing OBGYN. There's a lot I need to learn.

I have some concerns about the lack of oversight in clinic and triage as well, but I'm less concerned about those than the staffing for the L&D floor. This week was definitely better, but I'll just have to see how things are in the next few months, and how my actual L&D rotation goes. I appreciate all the discussion on this.

 

[michaelrack]

OB is different from other fields though in the sense that things can go very wrong, very quickly,.

things can go quickly wrong in other fields too, but not typically to a previously healthy 22 yo (and her infant). That's a lot different than things going bad with an eighty year old.

 

[Doctor4Life1769]

things can go quickly wrong in other fields too, but not typically to a previously healthy 22 yo (and her infant). That's a lot different than things going bad with an eighty year old.

Yeah, things can go quickly wrong in anesthesia, regardless of age.

 

[jl lin]

I'd be concerned if the 80 y.o. person was an otherwise and previously healthy individual. I see your point; but I think all human life is valuable. Things may need change when it becomes pretty clear that's it's someone's time to go.

Yes in critical areas I've been in a lot of codes; but there are a number of them where you could see it coming, b/c we are totally helicopters over the patients, but it's just that everything that was tried wouldn't work for one reason or another. With OB honestly things moving along nicely can suddenly get real ugly. I mean I started hemorrhaging out of no where during my last labor. I mean rivers strong enough that the OB practically threw the baby on me while packing, doing his deal, and firming stating repeatedly to "Put more Pit in the bag." I mean it was wild there for a while.

My mother had to be transfused with each of her deliveries. I had only one issue with not clotting and then a lot of clotting during my miscarriages and the issue of the last delivery. I had never had any bleeding problems during other C-sections.

OB is a place where it seems like you could get with the swing of business as usual, and then BOOM! Out of no where, in a matter of seconds, baby and mom are in trouble.

I think the angst is also over the fact that you are dealing with 2, or perhaps more in some cases, lives at one time--like in a matter of seconds. I think this is why a fair number of ED docs aren't all that thrilled with having pregnant or delivering moms come in w/ emergent needs/issues right then and there, the urgency may not allow time to wait for OB or for sending mom w/ coming baby up to OB.

Even as a patient, I have seen this. ED doc has to deal with my miscarriage, but seemed to prefer to avoid dealing with it, even though I had lost enough blood volume to be a difficult stick, and I am the EASIEST stick in the world--I mean from yards away practically. And as the patient, when you see your OB spin in to see you in ED, you do get this overwhelming sense of "Thank you God!" To this day, I am thankful for that doc. He saved and helped me many times, and he was always classy, caring, and highly competent. He's someone that was meant to do what he does. And I have no doubt that he deserves every penny he has every made as a doc--especially in OB.

 

[Crayola227]

Honestly, I would like to thank everyone for the replies and advice here. I did end up talking with my PD and it was brought up at a staff meeting and things seem to have improved a bit. OB is different from other fields though in the sense that things can go very wrong, very quickly, and I appreciate that people have brought that up. I am not someone who needs to have her hand held through everything for an entire year, but I am an intern in July doing OBGYN. There's a lot I need to learn.

I have some concerns about the lack of oversight in clinic and triage as well, but I'm less concerned about those than the staffing for the L&D floor. This week was definitely better, but I'll just have to see how things are in the next few months, and how my actual L&D rotation goes. I appreciate all the discussion on this.

Thanks for the update
Thanks for giving us feedback on the advice we gave you
While you did not take my advice of avoiding the PD (I use hyperbole purposefully when it come to PDs so people stop to think before knocking on their door), I am glad that you did and there was a good outcome. It's good to think twice about approaching the PD and I'm sure you considered it carefully, so it's a credit to you and the PD that this was a positive interaction. Pat on the back for your concern for patient safety, and taking reasonable action that made things better. Pat on the back for recognizing your limits and asking for help. Pat on the back for picking your battles and seeing how things evolve. You're an intern who sounds like did some good stuff, and I know as an intern you don't get many pats on back, so here you go.

Best of luck

 

[Crayola227]

things can go quickly wrong in other fields too, but not typically to a previously healthy 22 yo (and her infant). That's a lot different than things going bad with an eighty year old.

Yeah, things can go quickly wrong in anesthesia, regardless of age.

Agree wholeheartedly with both of you, and good teaching points.

Sometimes I tell dead baby jokes because without resorting to scatologic humor, violence, sexism, or racism, or making fun of religion or politics, they're easily the most offensive jokes there are. Why? Because there is nothing less funny than a dead baby. There is nothing worse than a dead baby. (Which I guess is why I find these jokes funny?)

When I think about it, I think there is only one specialty that completely avoids anything to do with babies or children under 12. In this field, the saddest thing you will ever see will NEVER be a dead baby. Not true of path, rads, optho, derm, anesthesia, psychiatry even, or sleep medicine, so every field but this one I'm thinking of gets a merit badge of bravery. I can envision a clinical scenario in each of those fields where one might end up with a dead baby. Totally bizarre and almost statistically impossible, but hypothetically possible Better to be in a field where SOC is to never have to train with or touch the precious little beasts.

 

[michaelrack]

I'd be concerned if the 80 y.o. person was an otherwise and previously healthy individual. I see your point; but I think all human life is valuable. .

I agree; all lives matter.

 

[Crayola227]

I agree; all lives matter.

They all matter, but let's face it, some matter more than most. At least to a jury in a court awarding damages.

(I don't personally believe that, I couldn't resist the joke, but if I'm overstaffed in an ED and it's between the baby and the 80 year old, there's really no choice in triage)

Obviously being in medicine isn't for the legal-liability faint-of-heart, but man, medical liability + babies = me shuddering

 

[ScalpElectrode]

So, things aren't really getting better. The clinics and triage are an absolutely awful mess. I've never seen clinics run so poorly anywhere.
I like residency, I love my field, but I think this program is terrible and it's showing from various angles. I really don't know what to do.

 

[Crayola227]

So, things aren't really getting better. The clinics and triage are an absolutely awful mess. I've never seen clinics run so poorly anywhere.
I like residency, I love my field, but I think this program is terrible and it's showing from various angles. I really don't know what to do.

It's a month and all the residents only have that much experience in their new roles. I don't know what that means for attending involvement, but if it's that bad, you could think of transfer, but realistically, you may just need to keep on keeping on. I remember being totally terrified at decisions I had to make in real time without input and then crossing my fingers it would all be OK, for the patient, and for whoever above me saw what I did after the fact. So many things were scary until I did them a few times and no one died or fired me, it's amazing how you really do settle in, you will adjust to chaos as the others in the program before you

Use common sense, find a survival guide, try to do what you can on your own to educate yourself, not only medically but also about the system you're in, be "efficient" as much as you can (I'm always putting in plugs on checking out my other posts on how to save yourself time as an intern) so you have more time at work to figure out how to work your system, ask for help when you can, CYA where you can.

This is ridiculous, but I actually spent like 5 min a day in an online app thing to practice typing faster early on when that was p*ssing me off. I should be reading medicine, but whatever is the bottleneck on your time gets addressed first, for me it was typing, then it was EKGs, so each thing that slowed me down most is what I addressed first. Identify what is the problem in clinic and triage and see if you can come up with a solution that will help you cope, or ask for help with it.

1) self-educate on medicine and the workings of your system
2) survival guides, organization of your own stuff
3) speed by doing the above
4) try to anticipate your need for help and put in the request for help ASAP, knowing there's always lagtime before you get a response
4) try to stall for time and not kill people while you wait for help
5) do what you think you can on your own if left to your own devices, fill in what you can and then go back for **** you wouldn't touch by yourself
6) Serenity Prayer: sort out what you can control, and try to let the rest go because you can drive yourself nuts with system issues you can't change
7) if you can pop your head up, see what others are dealing to deal and just do that, even if you know it sucks and is half-assed

it might help us give you advice if you identified in more detail the issues you're struggling with in this environment