Has anyone addressed the lack of autonomy in Peds residencies?

[MedicineZ0Z]

Wondering if this is an issue that has been discussed by any organization body of any kind at any point?
Every peds resident I've met or worked with from MS3 through to residency seems to be a combination of book smart/intelligent but constantly forced to double check decisions with someone else. The lack of independent decision making is pretty nuts. I just can't help but wonder if this an issue that's even addressed? Peds programs all offer good academic learning but actual clinical decision making is heavily minimized to only the most minor things.

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[deleted480308]

Wondering if this is an issue that has been discussed by any organization body of any kind at any point?
Every peds resident I've met or worked with from MS3 through to residency seems to be a combination of book smart/intelligent but constantly forced to double check decisions with someone else. The lack of independent decision making is pretty nuts. I just can't help but wonder if this an issue that's even addressed? Peds programs all offer good academic learning but actual clinical decision making is heavily minimized to only the most minor things.

They don’t even have their own “inbox” for patients at my institution. Just see patients on shift and the attendings get all the faxes/emails/emr questions/refills

 

[sloh]

They don’t even have their own “inbox” for patients at my institution. Just see patients on shift and the attendings get all the faxes/emails/emr questions/refills

Lol, in for a rude awakening once they are out practicing as attendings. In PM&R residency, it’s not unusual for residents to rate outpatient clinic as as more lifestyle friendly; but they never actually had to tend to inbox messages and return patient phone calls. They get a nice surprise once they are attendings with work bleeding into weeknights and weekends.

 

[MedicineZ0Z]

They don’t even have their own “inbox” for patients at my institution. Just see patients on shift and the attendings get all the faxes/emails/emr questions/refills

Which brings me to the point that this is all being a glorified secretary/scribe rather than an independent decision maker. And making independent decisions means at least being able to manage risky scenarios (where there are repercussions to being wrong) without any attending or fellow input, at least as a PGY3.

 

[FrkyBgStok]

Depends on the residency. At my program, they had a little more autonomy. Most in the ED and PICU. But I agree, in peds it is fairly rare.

One of the problems I see is just the dynamic with the parents. As an adult, if you go to a teaching facility, you deal with a lot of the things associated like med students and residents. With peds, parents often want the best and there is no way this resident is better than the neurologist. Nevermind the poor bedside manner, or the lack of access, he is a fully trained doctor and he is the best.

Another problem is just the implications. One problem I am seeing in fellowship with lack of autonomy is dealing with tail coverage. Being that one could be sued until this child turns 18 years of age, the attendings feel like they need to make the decision. I am curious where peds falls with lawsuits but one of the attendings in my program got sued a couple years ago so now all the attendings are fearful.

 

[calvnandhobbs68]

It's really hard because honestly everyone just cares about kids more than adults too. There are also less opportunities for procedures overall because kids tend to not get sick as often/have as many comorbidities and when they do, people (parents, nurses, hospital admin, fellows, attendings, everyone) cares a lot more. Everyone cares wayyy more if you f up that first try intubation on the 10 year old vs the 75 year old. Both from an emotional standpoint and a liability standpoint. Since the advent of improved neonatal care, vaccines and chemotherapy, the child mortality rate has been driven to such a low level in the US that child death or even adverse outcomes are seen as a very rare event (understandably) and everyone is very risk averse to anything that could contribute to bad outcomes.

The supervision is bleeding into all aspects of pediatrics though. There's more of a movement to onsite attendings in PICU and NICU overnight, NICU fellows now routinely go to most deliveries where "peds" is called or they just have NNPs going with minimal resident support, many fellows are over supervised.

This is one of the things that's most hilarious to me about NPs in peds. You have 3rd year residents who can't make decisions without running it by attendings but you have brand new NPs rounding on patients as "hospitalists" (which oh BTW a peds resident can't do without another "fellowship" for that at this point too).

 

[MedicineZ0Z]

Depends on the residency. At my program, they had a little more autonomy. Most in the ED and PICU. But I agree, in peds it is fairly rare.

One of the problems I see is just the dynamic with the parents. As an adult, if you go to a teaching facility, you deal with a lot of the things associated like med students and residents. With peds, parents often want the best and there is no way this resident is better than the neurologist. Nevermind the poor bedside manner, or the lack of access, he is a fully trained doctor and he is the best.

Another problem is just the implications. One problem I am seeing in fellowship with lack of autonomy is dealing with tail coverage. Being that one could be sued until this child turns 18 years of age, the attendings feel like they need to make the decision. I am curious where peds falls with lawsuits but one of the attendings in my program got sued a couple years ago so now all the attendings are fearful.

It's more that even routine things lack autonomy. Ex. getting a abd CT on a 15 year old at 3am is something that a PGY3 should be able to make the call on with zero attending input. Same with adding lab tests (something an intern should be able to do without approval) among other diagnostic workups.

It's really hard because honestly everyone just cares about kids more than adults too. There are also less opportunities for procedures overall because kids tend to not get sick as often/have as many comorbidities and when they do, people (parents, nurses, hospital admin, fellows, attendings, everyone) cares a lot more. Everyone cares wayyy more if you f up that first try intubation on the 10 year old vs the 75 year old. Both from an emotional standpoint and a liability standpoint. Since the advent of improved neonatal care, vaccines and chemotherapy, the child mortality rate has been driven to such a low level in the US that child death or even adverse outcomes are seen as a very rare event (understandably) and everyone is very risk averse to anything that could contribute to bad outcomes.

The supervision is bleeding into all aspects of pediatrics though. There's more of a movement to onsite attendings in PICU and NICU overnight, NICU fellows now routinely go to most deliveries where "peds" is called or they just have NNPs going with minimal resident support, many fellows are over supervised.

This is one of the things that's most hilarious to me about NPs in peds. You have 3rd year residents who can't make decisions without running it by attendings but you have brand new NPs rounding on patients as "hospitalists" (which oh BTW a peds resident can't do without another "fellowship" for that at this point too).

Our autonomy in FM/IM doesn't change for a 19 year old patient who was otherwise healthy and has an excellent future ahead of him/her.

I do agree that it is absurd that midlevels will have tons of autonomy but residents are essentially doing secretary work (ex. placing orders, writing notes, making calls, and reporting bedside assessments to higher ups).

And I wasn't aware that Peds is a highly sued specialty? Obgyn is sued relentlessly yet Ob residents often run the full show up until the baby is coming out (even then attendings are always hands off).

 

[calvnandhobbs68]

It's more that even routine things lack autonomy. Ex. getting a abd CT on a 15 year old at 3am is something that a PGY3 should be able to make the call on with zero attending input. Same with adding lab tests (something an intern should be able to do without approval) among other diagnostic workups.

Our autonomy in FM/IM doesn't change for a 19 year old patient who was otherwise healthy and has an excellent future ahead of him/her.

I do agree that it is absurd that midlevels will have tons of autonomy but residents are essentially doing secretary work (ex. placing orders, writing notes, making calls, and reporting bedside assessments to higher ups).

And I wasn't aware that Peds is a highly sued specialty? Obgyn is sued relentlessly yet Ob residents often run the full show up until the baby is coming out (even then attendings are always hands off).

Yes but that 19 year old patient is an adult. Who doesn't have parents who legally dictate his/her care. Who tend to not want residents ultimately running the show on their kid these days. A 19 year old is also much different than a 5 month old which is much different than a 5 year old which is much different than a 10 year old.

I don't think peds is a highly sued specialty (idk I'd have to look) but I agree that the possibly irrational liability fear is still there. Even the lowest sued specialties have like a 30% rate of lawsuits over the course of your career though (so pretty high chance of being ever sued).

I agree that it's the little day to day things that should really be left to the residents. But dumb stuff comes into play. Labs for instance. Again, people just "care" more. Nurses will bitch and moan and threaten you to make sure you actually order all the labs you want because they're not trying to stick that little cute 3 year old more than once before mom and dad come crying out of the room. So yeah, the intern ends up running all the labs by the senior/attending (or the seniors/attendings request they do) so they don't have to deal with this headache more than once a week (cause it still happens all the freaking time).

 

[FrkyBgStok]

A huge shame that NPs have more autonomy than residents.

This is a big problem for me. I am a fellow, a board certified pediatrician, and often I feel that NPs have more autonomy than me. And that just pisses me off.

 

[MedicineZ0Z]

Yes but that 19 year old patient is an adult. Who doesn't have parents who legally dictate his/her care. Who tend to not want residents ultimately running the show on their kid these days. A 19 year old is also much different than a 5 month old which is much different than a 5 year old which is much different than a 10 year old.

I don't think peds is a highly sued specialty (idk I'd have to look) but I agree that the possibly irrational liability fear is still there. Even the lowest sued specialties have like a 30% rate of lawsuits over the course of your career though (so pretty high chance of being ever sued).

I agree that it's the little day to day things that should really be left to the residents. But dumb stuff comes into play. Labs for instance. Again, people just "care" more. Nurses will bitch and moan and threaten you to make sure you actually order all the labs you want because they're not trying to stick that little cute 3 year old more than once before mom and dad come crying out of the room. So yeah, the intern ends up running all the labs by the senior/attending (or the seniors/attendings request they do) so they don't have to deal with this headache more than once a week (cause it still happens all the freaking time).

18-21 year olds get admitted to Peds and are treated the same as 2 year old patients. I agree that this is the usual excuse but it also makes residency kind of pointless. You don't retain things well until you're making the call. Hence PGY3s in Peds seem to all be very book smart but decision making is subpar. Then you end up with these hospitalist fellowships or even community GenPeds fellowships (lol).

And an intern who is being trained properly should know what labs to get for vast majority of scenarios halfway through the year. If IM/FM interns can manage DKA alone, then knowing to get basic labs isn't unrealistic for Peds.

 

[MedicineZ0Z]

It’s ironic since in pediatric surgical specialties (orthopaedics and otolaryngology, for example), residents and interns have a huge amount of autonomy, more than in other areas of surgery even. The academics in pediatrics must have done a terrible job in advocating for their trainees. A huge shame that NPs have more autonomy than residents.

The academic folks don't acknowledge this as an issue. Try suggesting anything that deviates from the expected plan to the academic peds hospitalist or outpatient attending. It'll be dismissed automatically. Things like IV fluid choices, electrolyte repletion, antibiotic choices and dosing among other things are mostly run by an attending or consultant before ordering.

 

[mvenus929]

This is a big problem for me. I am a fellow, a board certified pediatrician, and often I feel that NPs have more autonomy than me. And that just pisses me off.

The thing that annoys me more about being a fellow in my system is that I have to put my supervising physician's name on every single prescription I write despite the fact that I'm a board certified pediatrician and while some of the medications I prescribe are expensive, most are pretty routine. I end up putting in a random attending half the time because I don't remember who I saw the patient with and I'm not taking 5 minutes to look it up for a prescription for levothyroxine. Sorry.

But, I will say it depends on the program. In mine, the 3rd years called the shots on the floor overnight and the hospitalists would often let the 3rd years run the show during the day as well. Specialties it was a little more complex and depended on the trust of the attending in the senior. But even then, it's less--I worked out a plan for a patient I didn't want to extubate overnight in the NICU with the RT and RN and told the attending about it like 3 hours later (the baby was fine) and he said he wished I had run it by him first. I was mildly snarky with my calls after that.

 

[captianplanet]

It’s ironic since in pediatric surgical specialties (orthopaedics and otolaryngology, for example), residents and interns have a huge amount of autonomy, more than in other areas of surgery even. The academics in pediatrics must have done a terrible job in advocating for their trainees. A huge shame that NPs have more autonomy than residents.

Yeah, I am going to say this not true at where I have trained and currently work. Those residents' primary goal when rotating at a peds hospital is to to get peds OR time and ED exposure. The floor related care they have minimal if any autonomy and I actually would rather talk to the NPs over residents as they now the patients and hospital system significantly better. I do not fault the residents for this, cause day to day care is not why they are here. Though it is truly glaring and obvious when a resident makes a decision they weren't supposed to with the excuse of "that's what we do on the adult side." With those easy simple decisions you describe as should be "autonomous" end up leading to bigger ramifications for our pediatric patients, simply because they are not familiar with our system. So I would say, no, surgical residents do not have significantly more autonomy than peds residents at children's hospitals.

Which brings me to the point that this is all being a glorified secretary/scribe rather than an independent decision maker. And making independent decisions means at least being able to manage risky scenarios (where there are repercussions to being wrong) without any attending or fellow input, at least as a PGY3.

The academic folks don't acknowledge this as an issue. Try suggesting anything that deviates from the expected plan to the academic peds hospitalist or outpatient attending. It'll be dismissed automatically. Things like IV fluid choices, electrolyte repletion, antibiotic choices and dosing among other things are mostly run by an attending or consultant before ordering.

I am guessing you are not at an academic hospital system cause this is an ongoing issue.......I am also guessing you do not attend the pediatric program director meetings since this is always discussed on how to increase autonomy without compromising safety.

Safety in pediatrics trumps all, even autonomy. While in other specialties, this is can be seen as expected with resident teaching, you are kidding yourself if you think residency as a whole is not losing autonomy. You suggest Ob/Gyn is just running all over the place without supervision, but I can tell you this is drastically changing in favor of significantly more oversight for a multitude of different reasons. Internal medicine classically running the show without attendings, one safety error in a procedure that leads to ICU/death, you are kidding yourself that there won't be more oversight on all future procedures.
Frankly, there is just significantly less tolerance for medical error, which is not a bad thing.

Your main discussion piece is that pediatric residents can't decide without a discussion, which there is a valid point in that. The counterpoint is why do you have such an issue with discussing a decision with another person. 2 brains are better than 1, no? It is somewhat cavalier to think you will know every single decision or plan; discussion brings in extra insight to problems you may not have fully considered. Again, is that so bad for the patient?

No doubt, pediatrics training is not without its faults, and there is always room for improvement. And yes, residents should be given reinforcement to make simple decisions like labs/fluids/abx (which at my training/fellowship they were) but also do not fault a resident for discussing a patient's care. You may think little decisions such as abx are so easy, but I have seen AKI->dialysis for only on 48 hours of vanc. I have seen respiratory failure from volume overload of IV fluids. These are not just one offs and most are previously healthy before these events. While in adults, this could be deemed as multifactorial, in a child is a big miss in safety, which leads to more oversight that does trickle down to the loss of autonomy. Ultimately, we are all here to provide the best care for a child, and the risk of a medical error on a child should always be reduced as much as humanely possible. You may think this is overkill, but I would implore you to attend your next institution's safety review/RCA from a medical error, and reassess the idea that autonomy education should be favored over safety.

As a parent, would you rather go to a children's hospital that promotes resident education while compromising safety or a children's hospital that trains residents with an emphasis on safety? Hospitals are moving to more transparency, and patient safety information is becoming public data.....The excuse for error of "well, we are a teaching hospital" does not go over well with parents.

So yes some residents may waver on clinical decision making, which is a work in progress on how to improve. This is certainly not the majority of residents asking simple questions about "which lab should I order" and should be less than 25% of the program, IMO.

Not gonna lie, slightly annoyed that you have a problem with another physician wanting to discuss a care plan about a patient. No matter how trivial of a question, should never be frowned upon.

 

[Stitch]

This of course depends upon the institution as well as the individual resident involved. The service matters too. In the PICU we are pretty hands on involved. Our hospitalists are less so (because they don't need to be).

I will say that I am on several hospital committees in the adult hospital, including hospital M&M as well as root cause analysis. We routinely review cases of patient harm, near harm, and explore why it happened and how it can be prevented. There are a TON of dangerous scenarios that result in adult medicine directly from lack of supervision. This is especially true of specialties like neurosurgery and stems from multiple factors, including attendings who actively discourage calling for help. It's a very different culture. This lack of supervision is often talked about as giving trainees 'autonomy' but the fact is that we should never compromise the safety of a child in the name of autonomy.

It is possible and necessary to provide supervision and still give trainees autonomy. Maybe pediatrics needs to explore this more, but I can also tell you from my experiences with adult medicine that pediatricians from just about any program come out well trained as well as very consistent in their care and focus on patient safety. The concern with mid levels/APPs is valid, and I remember feeling this competition as a fellow, especially in the peds cvicu. It does get better and you will be fine when it's your turn in the pilot seat.

Medicine is changing, especially so with medical training. There are major problems with 'the way it used to be' but there will also be problems with newer solutions. I think things like more management with outpatient script requests makes sense, though this is difficult to fit in with work hours and other ACGME obligations. If you feel like you you're missing out on something I would talk directly to your PDs and attendings.

 

[WheezyBaby]

I'm med peds trained

There are a TON of dangerous scenarios that result in adult medicine directly from lack of supervision.

This I am 100% in agreement with

we should never compromise the safety of a child in the name of autonomy.

This I am not.

Anytime you're letting someone who isn't the most expert individual care for a patient, you're compromising safety to some degree, and that holds true beyond the trainee level. Should all complex lymphatic disorders go to chop, all hearts to Boston? Should an intensivist who isn't CV trained or cards double boarded spend any time covering a CVICU? From a trainee perspective, you can't tell me the patient the fellow is putting their first subclav in is just as safe as the patient having ped surg staff put in their 1000th. Likewise, if you're doing something as simple as letting your fellow run night rounds then loop you in after, that could undoubtedly contribute to late recognition of a deteriorating patient that may have done better with you present on rounds.

Without being arrogant, I think I was a damn fine resident, but there was at least 1 situation I can recall where my autonomous care led to not insignificant harm to a patient that would have been avoided with a more experienced physician. Medicine has room to improve from a patient safety standpoint. However, I am absolutely a stronger medicine than pediatric clinician, and I largely attribute that to the growth opportunities that autonomy affords. This peds mentality of firm handholding then father son holy spirit go forth my child sentiment after the somewhat meaningless transition from day before residency/fellowship graduation to day after grates on me. If you want excellent pediatric care in the future, you have to accept that comes at the cost of trainee autonomy and the associated risk to patient safety. It's not a simple balance to strike but the notion you can grant autonomy without any risk is flawed

 

[Lexdiamondz]

I'm med peds trained



This I am 100% in agreement with



This I am not.

Anytime you're letting someone who isn't the most expert individual care for a patient, you're compromising safety to some degree, and that holds true beyond the trainee level. Should all complex lymphatic disorders go to chop, all hearts to Boston? Should an intensivist who isn't CV trained or cards double boarded spend any time covering a CVICU? From a trainee perspective, you can't tell me the patient the fellow is putting their first subclav in is just as safe as the patient having ped surg staff put in their 1000th. Likewise, if you're doing something as simple as letting your fellow run night rounds then loop you in after, that could undoubtedly contribute to late recognition of a deteriorating patient that may have done better with you present on rounds.

Without being arrogant, I think I was a damn fine resident, but there was at least 1 situation I can recall where my autonomous care led to not insignificant harm to a patient that would have been avoided with a more experienced physician. Medicine has room to improve from a patient safety standpoint. However, I am absolutely a stronger medicine than pediatric clinician, and I largely attribute that to the growth opportunities that autonomy affords. This peds mentality of firm handholding then father son holy spirit go forth my child sentiment after the somewhat meaningless transition from day before residency/fellowship graduation to day after grates on me. If you want excellent pediatric care in the future, you have to accept that comes at the cost of trainee autonomy and the associated risk to patient safety. It's not a simple balance to strike but the notion you can grant autonomy without any risk is flawed

100% in agreement here.

Med-peds, FM and EM are the only three fields where a large percentage of your training is spent both caring for adults and kids...and when given a chance, most graduates from the aforementioned training pathways elect to see primarily adults. Part of that admittedly is financial in nature, but part of that also stems from the fact that we nearly all feel like much better clinicians when it comes to adult medicine vs peds. Our PGY3s and 4s run teams largely alone, run resuscitations and staff the ICUs overnight with no fellow or attending, meanwhile on the peds side of things I feel treated like a perpetual intern by attendings who have less experience with sick and dying patients than many of our junior residents.

I have the luxury of living in a geographic area where if I don't want to see kids, I don't have to. The vast majority of my residency cohort are availing themselves of this luxury.

Peds training is in crisis. When you get to the point that trainees who already spent 24/36 months of residency in hospital now require a fellowship to do hospitalist medicine, you've reached the point where a serious top-down re-examination of what the training goals of this pathway actually are absolutely needs to happen. At the risk of offending some here I'll honestly say there are alot of peds graduates (both from community and academic programs) who are going out into the real world and quite literally don't know how to do anything but wellchild visits. It's disgraceful.

 

[captianplanet]

med/peds always bring good perspectives

Should all complex lymphatic disorders go to chop, all hearts to Boston? Should an intensivist who isn't CV trained or cards double boarded spend any time covering a CVICU?

They do get sent to CHOP, and I am a large quintary center.... CHD goes to centers that routinely do those procedures Norwoods have better outcomes with centers with more experience. If Boston has the best outcomes and still is able to train fellows than fine go there, but if the outcomes are poor I don't care trainee/not trainee not sending. The outcome data is public knowledge and overall outcomes are huge part of pediatric hospitals in terms of catchment of additional patients. Referral hospitals won't refer to you if they are concerned about care given....which is drastically different than how adults hospitals are setup. We get referrals from out of state routinely, which is never really an option for adults.

So if improved safety leads to better outcomes ->not surprisingly that from a system standpoint resident education is going to be drastically different than adults.

It goes back to the same old saying a 2 y/o death or injury is more significant than a 88 y/o death/injury, which intrinsically mean less autonomy by a trainee.

This peds mentality of firm handholding then father son holy spirit go forth my child sentiment after the somewhat meaningless transition from day before residency/fellowship graduation to day after grates on me. If you want excellent pediatric care in the future, you have to accept that comes at the cost of trainee autonomy and the associated risk to patient safety. It's not a simple balance to strike but the notion you can grant autonomy without any risk is flawed

No doubt more hand-holding. End of the day it is risk assessment. Should an overnight senior resident be able to manage the floor patients without fellow/attending overisght. Absolutely. Should they be managing the ICU/onc/bmt floor autonomously, No. Which is a huge learning loss compared to adults. Additionally, while adults have codes all the time, a unplanned pediatric code occurs significantly less frequently and due to the infrequent repetition, shouldn't be run by a resident. Again there is a learning loss of that rapid decision making.

With so many adults now being admitted at children's hospitals considering an adult HM rotation for a month or two might drastically improve the autonomy decision making......

f things I feel treated like a perpetual intern by attendings

Unfortunately, I do agree med/peds residents experience this more frequently than they should.

Peds training is in crisis. When you get to the point that trainees who already spent 24/36 months of residency in hospital now require a fellowship to do hospitalist medicine, you've reached the point where a serious top-down re-examination of what the training goals of this pathway actually are absolutely needs to happen

I think a lot people misconstrue the goals of this fellowship. It is NOT to become competent in inpatient care. we can have a completely another conversation on this, but I will leave it at that.

 

[BigRedBeta]

Peds training is in crisis. When you get to the point that trainees who already spent 24/36 months of residency in hospital now require a fellowship to do hospitalist medicine, you've reached the point where a serious top-down re-examination of what the training goals of this pathway actually are absolutely needs to happen. At the risk of offending some here I'll honestly say there are alot of peds graduates (both from community and academic programs) who are going out into the real world and quite literally don't know how to do anything but wellchild visits. It's disgraceful.

I don't disagree with you, but part of what has gotten us to this point is that the "thought leaders" in pediatrics training have a wildly skewed view of how ready graduating residents are.

I've said this many times before, but I believe that the top children's hospitals have painted themselves in to a corner (not on purpose) by becoming quartenary or quintenary referral centers, such that a larger proportion of their patients far exceed what a regular general pediatrician needs to know. As such, they are fabulous places for fellows to train but the patients on many services are too complex for the peds residents to have any autonomy on. And while some people at these institutions will inevitably shout "we have bronchiolitics too!", the truth of the matter is that the culture of these locations has made it so that there's no incentive for residents to be autonomous even on the patients they should be able to manage without much difficulty. They residents also get bombarded with zebras and as such begin to think about those things much more frequently as possible diagnoses, which then brings in more consultants, and further abdication of the workup.

The result is that you have a whole bunch of very smart people graduating "The BEST*" </sarcasm> peds residencies ill-prepared for independent decision making. The medical education gurus run their projects on this group of residents, the results ignore the culture, and the conclusions end up being that the only answer is for more training, more education all with extended supervision.

There are programs out there that do encourage autonomy, maybe not to the extent of IM programs, but certainly that acknowledge what the end result of their program should be - individuals ready to be independent pediatricians, or capable fellows with a good understanding of general pediatrics. For example (just one of several) at my residency program (large free-standing program that took 25+ interns/yr, but by no means gets mentioned as a "big name"), interns always had to put in UVC/UAC in the NICU, and you got taught by your upper level resident how to do them, often with the admonishment that "pay attention and figure it out because next year you'll have to teach the interns", fellows only came to put in lines after the intern and resident had failed. The attendings frequently mentioned how important it was for everyone to know how to do lines because if someone went out to a rural part of the state, they might end up attending deliveries and needing to know how to do it, so again the reinforcement made it clear why it was an expectation.

Compare that to @SurfingDoctor 's PICU where residents begged off of writing daily progress notes - I can't imagine how that creates patient ownership and the ability to understand the day to day management. When I interviewed a decade ago for residencies I remember that some programs had suture techs and splinting techs in their ED's that got promoted as "that way you can focus on the sick kids", but nevermind that suturing and splinting are highly useful (and billable) skills for the general pediatrician. Again, it's not hard to foresee some program director thinking "if they want to learn those skills, they should go into a PEM fellowship...or maybe we could tack that on to our cutting edge outpatient pediatrics fellowship we're creating."

The question then becomes how is the cycle broken? You have to get a spot at the table with the decision makers, but to get a spot you need to be well regarded, which generally means your academic pedigree includes the very locations that produce these inadequately trained residents. It's a self-perpetuating cycle that lacks a clear answer

 

[WheezyBaby]

med/peds always bring good perspectives



They do get sent to CHOP, and I am a large quintary center.... CHD goes to centers that routinely do those procedures Norwoods have better outcomes with centers with more experience. If Boston has the best outcomes and still is able to train fellows than fine go there, but if the outcomes are poor I don't care trainee/not trainee not sending. The outcome data is public knowledge and overall outcomes are huge part of pediatric hospitals in terms of catchment of additional patients. Referral hospitals won't refer to you if they are concerned about care given....which is drastically different than how adults hospitals are setup. We get referrals from out of state routinely, which is never really an option for adults.

So if improved safety leads to better outcomes ->not surprisingly that from a system standpoint resident education is going to be drastically different than adults.

It goes back to the same old saying a 2 y/o death or injury is more significant than a 88 y/o death/injury, which intrinsically mean less autonomy by a trainee.



No doubt more hand-holding. End of the day it is risk assessment. Should an overnight senior resident be able to manage the floor patients without fellow/attending overisght. Absolutely. Should they be managing the ICU/onc/bmt floor autonomously, No. Which is a huge learning loss compared to adults. Additionally, while adults have codes all the time, a unplanned pediatric code occurs significantly less frequently and due to the infrequent repetition, shouldn't be run by a resident. Again there is a learning loss of that rapid decision making.

With so many adults now being admitted at children's hospitals considering an adult HM rotation for a month or two might drastically improve the autonomy decision making......


Unfortunately, I do agree med/peds residents experience this more frequently than they should.




I think a lot people misconstrue the goals of this fellowship. It is NOT to become competent in inpatient care. we can have a completely another conversation on this, but I will leave it at that.

Yeah in retrospect lymphatics was a poor example just based on exactly how niche it is. I stand by the rest. I was actually solo in house coverage for peds BMT as a resident and that was an excellent opportunity, but regardless I agree with the majority of your post - there should be different levels of autonomy on peds and medicine for multiple reasons. I hesitate to say a 2 yo death is more significant than an 80 yo death. It feels that way to me personally, and you could certainly make a utilitarian argument for that, but I hate to go in the direction of assigning differing value to life. There are other arguments that can be made for that differing autonomy like a lower physiologic reserve, resuscitation that is typically more dependent on successful intervention (airway management) and overall resuscitation skills as opposed to ACLS regurgitation due to the complex peri-arrest setting kids tend to go into rather than "has depressed EF, went into unstable VT". Not to say the management of the latter is simple, but the algorithm based management is more productive at least. My overarching point is that pediatricians can't go into it with the perspective of "there is no compromise for patient safety", because if that's the frame you approach trainee education from there is opportunity for no autonomy. It's all about balance.

Specifically as far as the fellowship goes, I agree and disagree. I think there are certainly plenty who feel it is necessary from a clinical care standpoint (see post above), but there are certainly many other skill sets developed through the fellowship

 

[DeadCactus]

Autonomy does not mean a lack of supervision. The point of autonomy should be to make independent decisions to see how things play out. The point of supervision is to provide bumper rails to keep blatantly harmful decisions from being made and to be able to have a meaningful conversation about the trainees decision making. The problem in pediatrics is not close supervision but a culture of micromanaging decisions when multiple acceptable answers exist.

My personal belief: Trainees should be forced to commit to a plan. The attending should discuss other options and what they would typically do. But then the trainee's plan should be implemented and only modified if it's a major safety issue. This empowers trainees to make decisions without every minor aspect being approved and gives them a chance to see how their decisions play out and learn if they want to do it the same way in the future or change their practice based on the discussion with the attending.

Unfortunately, on many pediatric services, what happens is the trainee's plan is micromanaged over nonsense like whether to get labs Q6H or Q8H, whether to use LR or NS, whether to wean the frequency or dose of albuterol, etc. The trainees have a learned helplessness instilled in them and the pattern reinforces itself.


As an aside, I think the issue of the pediatric hospitalist fellowships is overblown. The reality is some sort of fellowship training is the expectation for academic positions in many specialties and the era of going from residency to a faculty position is drawing to a close. I find it doubtful that community hospitalist jobs will generally require fellowship training.

 

[WheezyBaby]

I don't disagree with you, but part of what has gotten us to this point is that the "thought leaders" in pediatrics training have a wildly skewed view of how ready graduating residents are.

I've said this many times before, but I believe that the top children's hospitals have painted themselves in to a corner (not on purpose) by becoming quartenary or quintenary referral centers, such that a larger proportion of their patients far exceed what a regular general pediatrician needs to know. As such, they are fabulous places for fellows to train but the patients on many services are too complex for the peds residents to have any autonomy on. And while some people at these institutions will inevitably shout "we have bronchiolitics too!", the truth of the matter is that the culture of these locations has made it so that there's no incentive for residents to be autonomous even on the patients they should be able to manage without much difficulty. They residents also get bombarded with zebras and as such begin to think about those things much more frequently as possible diagnoses, which then brings in more consultants, and further abdication of the workup.

The result is that you have a whole bunch of very smart people graduating "The BEST*" </sarcasm> peds residencies ill-prepared for independent decision making. The medical education gurus run their projects on this group of residents, the results ignore the culture, and the conclusions end up being that the only answer is for more training, more education all with extended supervision.

There are programs out there that do encourage autonomy, maybe not to the extent of IM programs, but certainly that acknowledge what the end result of their program should be - individuals ready to be independent pediatricians, or capable fellows with a good understanding of general pediatrics. For example (just one of several) at my residency program (large free-standing program that took 25+ interns/yr, but by no means gets mentioned as a "big name"), interns always had to put in UVC/UAC in the NICU, and you got taught by your upper level resident how to do them, often with the admonishment that "pay attention and figure it out because next year you'll have to teach the interns", fellows only came to put in lines after the intern and resident had failed. The attendings frequently mentioned how important it was for everyone to know how to do lines because if someone went out to a rural part of the state, they might end up attending deliveries and needing to know how to do it, so again the reinforcement made it clear why it was an expectation.

Compare that to @SurfingDoctor 's PICU where residents begged off of writing daily progress notes - I can't imagine how that creates patient ownership and the ability to understand the day to day management. When I interviewed a decade ago for residencies I remember that some programs had suture techs and splinting techs in their ED's that got promoted as "that way you can focus on the sick kids", but nevermind that suturing and splinting are highly useful (and billable) skills for the general pediatrician. Again, it's not hard to foresee some program director thinking "if they want to learn those skills, they should go into a PEM fellowship...or maybe we could tack that on to our cutting edge outpatient pediatrics fellowship we're creating."

The question then becomes how is the cycle broken? You have to get a spot at the table with the decision makers, but to get a spot you need to be well regarded, which generally means your academic pedigree includes the very locations that produce these inadequately trained residents. It's a self-perpetuating cycle that lacks a clear answer

I'm not sure where Surfing is, I'm familiar with at least one PICU program where that note-writing quirk is the case, though it's been that way for quite some years. If it's the same institution, the residents still write admit notes (and maybe discharge summaries?), so there is some opportunity there. I can see it in either direction. For a motivated resident, I think it would overall be a positive. The benefit to note writing is the opportunity to sit down, really make sure you have a fleshed out clinical picture of what's happening, and materialize that understanding in a succinct way that offers staff an additional opportunity to see where there may have been misunderstanding. With that said, notes can be a big time investment when written well, and if eliminating most note writing significantly improved resident ability to be at the bedside, have more frequent didactic education, participate in sims, etc, I'm not sure it's the wrong move, particularly if there are borderline duty hours issues. For an unmotivated resident, it does likely detract from their education. Interesting approach though one way or the other.

 

[WheezyBaby]

Autonomy does not mean a lack of supervision. The point of autonomy should be to make independent decisions to see how things play out. The point of supervision is to provide bumper rails to keep blatantly harmful decisions from being made and to be able to have a meaningful conversation about the trainees decision making. The problem in pediatrics is not close supervision but a culture of micromanaging decisions when multiple acceptable answers exist.

My personal belief: Trainees should be forced to commit to a plan. The attending should discuss other options and what they would typically do. But then the trainee's plan should be implemented and only modified if it's a major safety issue. This empowers trainees to make decisions without every minor aspect being approved and gives them a chance to see how their decisions play out and learn if they want to do it the same way in the future or change their practice based on the discussion with the attending.

Unfortunately, on many pediatric services, what happens is the trainee's plan is micromanaged over nonsense like whether to get labs Q6H or Q8H, whether to use LR or NS, whether to wean the frequency or dose of albuterol, etc. The trainees have a learned helplessness instilled in them and the pattern reinforces itself.


As an aside, I think the issue of the pediatric hospitalist fellowships is overblown. The reality is some sort of fellowship training is the expectation for academic positions in many specialties and the era of going from residency to a faculty position is drawing to a close. I find it doubtful that community hospitalist jobs will generally require fellowship training.

I largely agree here, and that micromanagement leading to learned helplessness I think is a valuable point. I will say opportunity for indirect supervision adds to education (if someone isn't going to just tell you "no that's wrong", your investment in really thinking out your decision making process is going to be higher), but I agree it is not an essential component of autonomy per se.

As far as the fellowship, I'd just leave this

However, fewer than 50% of respondents felt that the practice of hospitalist medicine was
“unique from general pediatrics and/or any other area of established subspecialty medicine.” Further, only 30% of respondents believed that the practice of hospitalist medicine requires a unique body of knowledge and has a unique scientific basis. Correspondingly, only 16% of respondents supported a separate board certification and 62% of respondents thought that hospitalists’ training could be accomplished without additional training and separate board certification

From this paper

"Hospitalist Medicine—Chairs' Perspective of Specialty Status and Training Requirements"

 

[aafisahar]

My personal belief: Trainees should be forced to commit to a plan. The attending should discuss other options and what they would typically do. But then the trainee's plan should be implemented and only modified if it's a major safety issue. This empowers trainees to make decisions without every minor aspect being approved and gives them a chance to see how their decisions play out and learn if they want to do it the same way in the future or change their practice based on the discussion with the attending.

I disagree. There is too much hierarchial inertia in having the attending present alternatives. Invariably, when I present alternatives to the residents, they go with my plan, because I'm the fellow and therefore I know better, when in reality, their plan was equally as good as mine. True autonomy is being able to make decisions without any attending oversight or input. For example, last year, as a first year cards fellow, I made the call to place a temp wire in a patient who I determined needed it and didn't have any attending input/oversight for >12 hours. In residency, I would admit 10+ patients/night in the ICU without any in-house attending or fellow. I had a serotonin syndrome patient who kept having clonus despite sedation, so I deep sedated the **** out of him (eg 200mcg/hr propofol + 10mg/hr versed) in order to prevent his brain from frying. I had CV surgery come by and cannulate a refractory ARDS for ECMO. Not having attendings look every my shoulders for every small detail made me a stronger clinician for it.

Trainees need to feel like they can make decisions without running it by 3 levels of supervision. No attending needs to know that you put in an order for tylenol. There needs to be a healty level of separation between the patient and the attending.

 

[DeadCactus]

I disagree. There is too much hierarchical inertia in having the attending present alternatives. Invariably, when I present alternatives to the residents, they go with my plan, because I'm the fellow and therefore I know better, when in reality, their plan was equally as good as mine.

That's why they present their plan first and then that IS the plan. It's not a decision of what plan to go with it, they've already chosen. This requires attendings to be able to do that, which many pediatric attendings seem to struggle with, but it is possible. Not having the discussion just robs them of the chance to learn how more experienced clinicians make decisions and having it in real time lets them compare their current plan to how the alternative plan may have been working out as the clinical course plays out. Looking at things retrospectively when all the outcomes are known doesn't provide the same experience.

I'm not saying an attending needs to hover over the shoulder of every single trainee at every moment of the day. As trainees advance, the assumption should be that more and more decisions should no longer be approached as a trainee learning to do something and more as a colleague making competent decisions. Supervision and education should then move on to more advanced clinical problems.

My point is that the solution to micromanaging isn't abandonment. You can abandon a trainee to make decisions and then throw them under the bus when you come back and destroy their confidence and willingness to make independent decisions just as easily as you can smother it with micromanagement. I would argue that forcing them to pick a plan and then moving forward with that plan even if it differs with the attending's plan demonstrates that there are multiple reasonable answers and empowers a learner to make a decision and act on it. At the end of the day, attendings need to be actively engaged in the education of their trainees and micromanaging and abandonment are both just ways of shirking that responsibility.

 

[doopdidoop]

I disagree. There is too much hierarchial inertia in having the attending present alternatives. Invariably, when I present alternatives to the residents, they go with my plan, because I'm the fellow and therefore I know better, when in reality, their plan was equally as good as mine. True autonomy is being able to make decisions without any attending oversight or input. For example, last year, as a first year cards fellow, I made the call to place a temp wire in a patient who I determined needed it and didn't have any attending input/oversight for >12 hours. In residency, I would admit 10+ patients/night in the ICU without any in-house attending or fellow. I had a serotonin syndrome patient who kept having clonus despite sedation, so I deep sedated the **** out of him (eg 200mcg/hr propofol + 10mg/hr versed) in order to prevent his brain from frying. I had CV surgery come by and cannulate a refractory ARDS for ECMO. Not having attendings look every my shoulders for every small detail made me a stronger clinician for it.

Trainees need to feel like they can make decisions without running it by 3 levels of supervision. No attending needs to know that you put in an order for tylenol. There needs to be a healty level of separation between the patient and the attending.

to be fair there's a big difference between running your tylenol dose through an attending and cannulating a patient for ECMO - and your body of experience comes from the internal medicine world where the volume of ECMO cannulation in a medical ICU far outpaces what pediatric practitioners see at comparable institutions. i agree that micromanagement has to go, but there are ways to balance patient safety and outcome, which is heightened in pediatrics (whether fair or not, that's another discussion), while creating space to learn, make plans, and be provided a safety net. it's a hard balance to have and i can't say that i consistently experienced this as a pediatric trainee but something we should strive towards.

 

[mvenus929]

I disagree. There is too much hierarchial inertia in having the attending present alternatives. Invariably, when I present alternatives to the residents, they go with my plan, because I'm the fellow and therefore I know better, when in reality, their plan was equally as good as mine. True autonomy is being able to make decisions without any attending oversight or input. For example, last year, as a first year cards fellow, I made the call to place a temp wire in a patient who I determined needed it and didn't have any attending input/oversight for >12 hours. In residency, I would admit 10+ patients/night in the ICU without any in-house attending or fellow. I had a serotonin syndrome patient who kept having clonus despite sedation, so I deep sedated the **** out of him (eg 200mcg/hr propofol + 10mg/hr versed) in order to prevent his brain from frying. I had CV surgery come by and cannulate a refractory ARDS for ECMO. Not having attendings look every my shoulders for every small detail made me a stronger clinician for it.

Trainees need to feel like they can make decisions without running it by 3 levels of supervision. No attending needs to know that you put in an order for tylenol. There needs to be a healty level of separation between the patient and the attending.

I, personally, need to be better at getting the residents to think through the questions they're asking me and come up with some sort of plan. Some are great at it and I have nothing to add; others call and don't offer any plan and expect me to tell it to them. But the decisions you're describing are far more than what most pediatric trainees are going to experience, period (with or without attending oversight). When I did my second PICU rotation, I sat by the bedside of my two sickest patients all night and made the majority of the decisions on my own. When something didn't go as I expected it to and I was stumped on what to do next, I called the attending.

As a senior fellow, the vast majority of the time, the attending goes with my plan. They discuss alternative ways of doing things, but as long as my plan is reasonable, they go with it. The patients I get stumped on are the ones they have to think about too, and are often calling other attendings to ask for input.

It's not a sign of weakness to ask for help, or to run plans by more senior colleagues. Yes, residents need to feel somewhat comfortable making decisions on their own before graduation, but running things by another person is not a bad thing.

 

[DO2015CA]

I train at a program thats goal to is to produce autonomous residents that can become general pediatricians to enter the rural areas that comprise the vast majority of the state. For me, autonomy isn't an issue, but I understand that its a problem with a large portion of residencies today. The question becomes how do I, as a resident coming out as a new graduate convince these hiring agencies that I am capable of pediatric hospitalist at a non-BMS childrens hospital without a hospitalist fellowship?

 

[MedicineZ0Z]

Yeah, I am going to say this not true at where I have trained and currently work. Those residents' primary goal when rotating at a peds hospital is to to get peds OR time and ED exposure. The floor related care they have minimal if any autonomy and I actually would rather talk to the NPs over residents as they now the patients and hospital system significantly better. I do not fault the residents for this, cause day to day care is not why they are here. Though it is truly glaring and obvious when a resident makes a decision they weren't supposed to with the excuse of "that's what we do on the adult side." With those easy simple decisions you describe as should be "autonomous" end up leading to bigger ramifications for our pediatric patients, simply because they are not familiar with our system. So I would say, no, surgical residents do not have significantly more autonomy than peds residents at children's hospitals.






I am guessing you are not at an academic hospital system cause this is an ongoing issue.......I am also guessing you do not attend the pediatric program director meetings since this is always discussed on how to increase autonomy without compromising safety.

Safety in pediatrics trumps all, even autonomy. While in other specialties, this is can be seen as expected with resident teaching, you are kidding yourself if you think residency as a whole is not losing autonomy. You suggest Ob/Gyn is just running all over the place without supervision, but I can tell you this is drastically changing in favor of significantly more oversight for a multitude of different reasons. Internal medicine classically running the show without attendings, one safety error in a procedure that leads to ICU/death, you are kidding yourself that there won't be more oversight on all future procedures.
Frankly, there is just significantly less tolerance for medical error, which is not a bad thing.

Your main discussion piece is that pediatric residents can't decide without a discussion, which there is a valid point in that. The counterpoint is why do you have such an issue with discussing a decision with another person. 2 brains are better than 1, no? It is somewhat cavalier to think you will know every single decision or plan; discussion brings in extra insight to problems you may not have fully considered. Again, is that so bad for the patient?

No doubt, pediatrics training is not without its faults, and there is always room for improvement. And yes, residents should be given reinforcement to make simple decisions like labs/fluids/abx (which at my training/fellowship they were) but also do not fault a resident for discussing a patient's care. You may think little decisions such as abx are so easy, but I have seen AKI->dialysis for only on 48 hours of vanc. I have seen respiratory failure from volume overload of IV fluids. These are not just one offs and most are previously healthy before these events. While in adults, this could be deemed as multifactorial, in a child is a big miss in safety, which leads to more oversight that does trickle down to the loss of autonomy. Ultimately, we are all here to provide the best care for a child, and the risk of a medical error on a child should always be reduced as much as humanely possible. You may think this is overkill, but I would implore you to attend your next institution's safety review/RCA from a medical error, and reassess the idea that autonomy education should be favored over safety.

As a parent, would you rather go to a children's hospital that promotes resident education while compromising safety or a children's hospital that trains residents with an emphasis on safety? Hospitals are moving to more transparency, and patient safety information is becoming public data.....The excuse for error of "well, we are a teaching hospital" does not go over well with parents.

So yes some residents may waver on clinical decision making, which is a work in progress on how to improve. This is certainly not the majority of residents asking simple questions about "which lab should I order" and should be less than 25% of the program, IMO.

Not gonna lie, slightly annoyed that you have a problem with another physician wanting to discuss a care plan about a patient. No matter how trivial of a question, should never be frowned upon.

I am at an academic hospital dude. And why is having to discuss everything a bad thing? Because PGY3 in May has to run things by someone senior, then in August of that same year they're now all alone as an attending in a community hospital without any real back up to run their decisions by. Now what? Does the kid in that community hospital matter less? Or is this just a silly excuse to justify extreme lack of autonomy? Because failure of a program to train that Peds for their August job mean the system is not educating properly.

And I know well about volume overload from IVF and antibiotics causing AKIs. I do mostly adult medicine. I see those two things multiple times per day, everyday. If residents in the same hospital are managing a 22 year old's abx and fluids alone, they can manage a fully grown17 year olds as well. Yet the latter will need every decision run by someone senior.

 

[andrek82]

I am at an academic hospital dude. And why is having to discuss everything a bad thing? Because PGY3 in May has to run things by someone senior, then in August of that same year they're now all alone as an attending in a community hospital without any real back up to run their decisions by. Now what? Does the kid in that community hospital matter less? Or is this just a silly excuse to justify extreme lack of autonomy? Because failure of a program to train that Peds for their August job mean the system is not educating properly.

And I know well about volume overload from IVF and antibiotics causing AKIs. I do mostly adult medicine. I see those two things multiple times per day, everyday. If residents in the same hospital are managing a 22 year old's abx and fluids alone, they can manage a fully grown17 year olds as well. Yet the latter will need every decision run by someone senior.

Am I right in guessing you are FM then? If so, the degree of peds inpt care is so low as to not be that helpful except in rare programs. You are right that the 17yo gastroenteritis patient is no big deal for anyone comfortable with hospital medicine. If you graduate FM or EM or some similarly adult heavy/peds light system, the peds bread and butter such as asthma or dehydration or newborn jaundice should be okay, but beyond that I hope there is a Peds/MedPeds doc on board. That is a completely different discussion from peds autonomy.

 

[SurfingDoctor]

I don't mind autonomy as long as someone runs it by me. It my name in the chart, not some trainee. Anything that happens to that child that is undesirable, it is my fault... no one elses. That is the bottom line. I've seen enough people do all sort of stupid stuff and hurt kids, I want to minimize that as much as possible. If anyone has a goal that is different, they probably shouldn't be practicing anything but tic tac toe.

Now, it one wants to argue about the utility of other fellowships, so be it. I am not a personal fan of the hospitalist medicine fellowship because I don't think doing an MPH or whatever makes one a better clinician at all, but we also shouldn't kid ourselves that that fellowship developed due to clinical skills needs. It comes from the same misguided beliefs that pediatricians need to be researchers and scholars. Of course, a vast majority aren't and that's fine, but the antiquated notion remains. But, that has nothing to do with autonomy or my point above.

 

[SurfingDoctor]

I disagree. There is too much hierarchial inertia in having the attending present alternatives. Invariably, when I present alternatives to the residents, they go with my plan, because I'm the fellow and therefore I know better, when in reality, their plan was equally as good as mine. True autonomy is being able to make decisions without any attending oversight or input. For example, last year, as a first year cards fellow, I made the call to place a temp wire in a patient who I determined needed it and didn't have any attending input/oversight for >12 hours. In residency, I would admit 10+ patients/night in the ICU without any in-house attending or fellow. I had a serotonin syndrome patient who kept having clonus despite sedation, so I deep sedated the **** out of him (eg 200mcg/hr propofol + 10mg/hr versed) in order to prevent his brain from frying. I had CV surgery come by and cannulate a refractory ARDS for ECMO. Not having attendings look every my shoulders for every small detail made me a stronger clinician for it.

Trainees need to feel like they can make decisions without running it by 3 levels of supervision. No attending needs to know that you put in an order for tylenol. There needs to be a healty level of separation between the patient and the attending.

I take it you've never seen a trainee give 50 cc/kg of blood to a patient? Or given them 10 mg/kg of Lasix (who wasn't completely anuric already)? Or put a chest tube into the left ventricle? Give it time... you will.

Fortunately... even without a attending around 24/7 (because of course, they can make mistake too), there are many layers to patient care that allow for oversight of trainees.

 

[MedicineZ0Z]

Am I right in guessing you are FM then? If so, the degree of peds inpt care is so low as to not be that helpful except in rare programs. You are right that the 17yo gastroenteritis patient is no big deal for anyone comfortable with hospital medicine. If you graduate FM or EM or some similarly adult heavy/peds light system, the peds bread and butter such as asthma or dehydration or newborn jaundice should be okay, but beyond that I hope there is a Peds/MedPeds doc on board. That is a completely different discussion from peds autonomy.

We admit complex Peds to our service all the time. They're subspecialty driven just like how they would be on a Peds service.

I don't mind autonomy as long as someone runs it by me. It my name in the chart, not some trainee. Anything that happens to that child that is undesirable, it is my fault... no one elses. That is the bottom line. I've seen enough people do all sort of stupid stuff and hurt kids, I want to minimize that as much as possible. If anyone has a goal that is different, they probably shouldn't be practicing anything but tic tac toe.

Now, it one wants to argue about the utility of other fellowships, so be it. I am not a personal fan of the hospitalist medicine fellowship because I don't think doing an MPH or whatever makes one a better clinician at all, but we also shouldn't kid ourselves that that fellowship developed due to clinical skills needs. It comes from the same misguided beliefs that pediatricians need to be researchers and scholars. Of course, a vast majority aren't and that's fine, but the antiquated notion remains. But, that has nothing to do with autonomy or my point above.

That's fair as long as you watch your midlevels tightly too and not let them do what they want while you stick to PGY3 decisions like glue.

And you guys make it sound like errors can't happen in adult medicine.

 

[DeadCactus]

I train at a program thats goal to is to produce autonomous residents that can become general pediatricians to enter the rural areas that comprise the vast majority of the state. For me, autonomy isn't an issue, but I understand that its a problem with a large portion of residencies today. The question becomes how do I, as a resident coming out as a new graduate convince these hiring agencies that I am capable of pediatric hospitalist at a non-BMS childrens hospital without a hospitalist fellowship?

The fellowship is not about clinical competence. The fellowship is about hoop jumping and developing a niche. Fellowship training will increasingly become the norm at academic medical centers and likely remain irrelevant at community hospitals. It's no different than most other specialties and subspecialties. It's not uncommon for intensivists, emergency physicians, surgeons, cardiologists, etc to require additional training and specialization to break into larger academic medical centers. The trend is worse in pediatrics because the relatively concentrated nature of specialized care but will be the overall trend for medicine as a whole.

 

[MedicineZ0Z]

The fellowship is not about clinical competence. The fellowship is about hoop jumping and developing a niche. Fellowship training will increasingly become the norm at academic medical centers and likely remain irrelevant at community hospitals. It's no different than most other specialties and subspecialties. It's not uncommon for intensivists, emergency physicians, surgeons, cardiologists, etc to require additional training and specialization to break into larger academic medical centers. The trend is worse in pediatrics because the relatively concentrated nature of specialized care but will be the overall trend for medicine as a whole.

Unless you're a midlevel, you just start the same job (that needs a decade of endless silly fellowships) straight out of school - working 4 days a week for 110k. Then move onto another specialized job 2 years later overnight.
You also do what you like, while senior residents have to ask about everything they want to do.

 

[DeadCactus]

And pediatricians can go get a job making 200k for 4 days of work. It’s just generally not going to be as a hospitalist in a major urban medical center.

The fellowship came to exist because physicians are willing to do extra training and make less money to live in major cities and work at major academic centers. That has nothing to do with mid-levels. You’re not entitled to a job others are willing to do for cheaper and with more qualifications and the need for a fellowship to land an academic job is not unique to pediatric hospitalist.

 

[SurfingDoctor]

We admit complex Peds to our service all the time. They're subspecialty driven just like how they would be on a Peds service.

That's fair as long as you watch your midlevels tightly too and not let them do what they want while you stick to PGY3 decisions like glue.

And you guys make it sound like errors can't happen in adult medicine.

Everyone gets watched when it's my name in the chart. As the adage goes "Trust, but verify"

 

[PTPoeny]

Everyone gets watched when it's my name in the chart. As the adage goes "Trust, but verify"

And that goes for the resident or APP putting in orders and the nurse carrying them out. The APPs that I work with everyday

We admit complex Peds to our service all the time. They're subspecialty driven just like how they would be on a Peds service.

That's fair as long as you watch your midlevels tightly too and not let them do what they want while you stick to PGY3 decisions like glue.

And you guys make it sound like errors can't happen in adult medicine.

I wonder if you don't see it but it is happening? At my hospital the residents are much more likely to come find me in person to let me know what is happening and what they want to do. The APPs are more likely to use the hospital approved text messaging program. But yes, they all need to be letting me know what they are doing because I am responsible.

 

[captianplanet]

I am at an academic hospital dude. And why is having to discuss everything a bad thing? Because PGY3 in May has to run things by someone senior, then in August of that same year they're now all alone as an attending in a community hospital without any real back up to run their decisions by. Now what? Does the kid in that community hospital matter less? Or is this just a silly excuse to justify extreme lack of autonomy? Because failure of a program to train that Peds for their August job mean the system is not educating properly.

And I know well about volume overload from IVF and antibiotics causing AKIs. I do mostly adult medicine. I see those two things multiple times per day, everyday. If residents in the same hospital are managing a 22 year old's abx and fluids alone, they can manage a fully grown17 year olds as well. Yet the latter will need every decision run by someone senior.

The complexity of a community hospital admit is exponentially less than larger teritary+ centers with the majority of admits bread n butter related. Yes, if a PGY3 cannot manage these patients then there is a problem, but I do not think this is the majority of programs out there even with the concerns with too much oversight. Additionally, just as I am sure your program offered there will also be attendings that say call me anytime even when you feel you are alone. I have offered that to any resident that I have come across, and will continue to do so. Discussing a patient should never be frowned upon.

In regards to your exp, then you know mistakes happen and patient harm does occur. While they do occur in adults, in peds its just less tolerated. I don't think many here are disagreeing with you that a previously healthy 17 y/o with gastro or pyelo should need much oversight and considered bread n butter. Again if where you are is like that, then I would think this is more program-specific than blanket statement to all peds. I did HM at a community hospital right after residency and had no issues with that transition.

Unless you're a midlevel, you just start the same job (that needs a decade of endless silly fellowships) straight out of school - working 4 days a week for 110k. Then move onto another specialized job 2 years later overnight.
You also do what you like, while senior residents have to ask about everything they want to do.

I have a feeling you absolutely hate midlevels. Inpatient is not like a clinic environment where the APRN has a ton of autonomy. Midlevels inpatient round and participate just as a resident would and has the same amount of oversight that you determine to be overkill. Also most midlevels take 6 months plus on the same service to gain trust from the attendings which is not an insignificant amount of time/training. There are many services where APRNs are actually superior to residents IMO. I know that is hard to believe but if you only deal with transplant patients and have been working the same service and know the patients, that might actually be better than a resident who rotates through for 1 month.

It only takes you seeing one complex kid crump to step back and say should I have done something different. It sucks to see a kid die and that by itself may be a driving force behind peds residents being overly cautious.

 

[captianplanet]

We admit complex Peds to our service all the time. They're subspecialty driven just like how they would be on a Peds service.

I think this may be a testament of your peds program, and your concerns of their training may also be validated by the subspecialists. I have honestly never seen a peds subspecialist choose FM over peds when admitting to an HM service. Granite, I have always been at centers who have limited admitting privileges to predominately peds HM, but maybe my experience is not the norm.

 

[DO2015CA]

I think this may be a testament of your peds program, and your concerns of their training may also be validated by the subspecialists. I have honestly never seen a peds subspecialist choose FM over peds when admitting to an HM service. Granite, I have always been at centers who have limited admitting privileges to predominately peds HM, but maybe my experience is not the norm.

Ya our sub specialists are all consults to our main service. Even for complex kids, CF is the really only thing I see specialists driving anything and its just the abx they want

 

[hmockingbird]

I definitely think it can be an issue but depends on the program. At my residency it depended on the attending during the day (some were more micromanage-y than others) but we were alone overnight. I always heard from my med/peds friends that they had more autonomy on medicine, yet where I’m working now I feel like the residents have less initiative than at my residency. We were expected to do EVERYTHING ourselves. In other ways, where I work they are more independent earlier because they transition to the senior role sooner. So I can see how it’s program dependent.

I trained at an academic center, highly inpatient heavy, and now work at an academic center as a hospitalist. I honestly had a great transition. To me the fellowship is more for networking and research and it’s unfortunate that it’s trending towards being required. It would’ve been worthless to me.

 

[zeppelinpage4]

It’s definitely a real issue and something we’ve noticed when compared to IM residents at our hospital. My programs saving grace is that we don’t have attending in house during night shifts in PICU and our floor, so residents get to run the show a bit more during the night.

I doubt any governing body is doing anything to address this. They’re so insanely out of touch with reality in academic peds it’s ridiculous. Requiring 3 years across the board for fellowships, especially fields like adolescent medicine and now requiring a hospitalist fellowship is total BS. I almost doubted my specialty choice because the people up top seem so out of touch with the realities of medicine. I really like peds as a field for what it is, but def don’t fit in with the culture, especially in academics.

 

[Socrates25]

I was med/peds

In my peds residency on the general peds floor we ran everything as PGY-2 and PGY-3s with zero attending input unless we had questions.

In PICU and NICU we would have a brief conversation for every new admit but there wasn't a lot of micromanaging.

The subspecialty services definitely involved more hands-on attending involvement, for nephrology patients were given explicit instructions on which fluids to run, etc

Obviously the most important reason why peds is less autonomous is that old people are considered a lot more "expendable" than kids are, that's just the honest truth. There were very few adult ICU codes that caused residents or attendings any consternation or doubts about our course of action. The majority of my adult ICU codes had zero fellows or attending present.

Second reason as to why peds are less autonomous is because frankly codes and other critically ill patients are a lot more frequent on the adult side, and that extra exposure encourages attendings to be more "cavalier" with respect to letting residents run things. On my adult ICU shifts we would often have 4-5 codes, whereas in PICU that never happened. One of my PICU months only had 5 codes for the entire month.