How depressed are you supposed to get on MS3 surgery?

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DermViser said:
Obviously, they're not competent if they have to keep paging Surgery to help them with their screwups. My understanding is now the ACGME no longer has procedure # requirements for IM like they used to.
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Oh I obviously completely agree. I've seen "senior" medicine residents "supervising" lines in the ICU when they've only put in 2 lines themselves. It's just not safe. But the fellows and attendings expect the residents to do them...so they do...

I can't even convince them to try transducing the venous pressure before they cannulate.

I've also seen a straight kill from a bedside procedure by a medicine resident...twice. That's pretty sobering.

I think the way to do it successfully at my institution would be to turn it into a multidisciplinary thing with all the specialties (medicine, anesthesia, surgery, EM) that do lines. But we don't have any buy-in for it at present.
 
southernIM said:
Triple lumen in the carotid ain't that bad...
Medically isn't that bad, even in though it was a pre-liver with a MELD of 42, it really isn't the end of the world or even hard to 'fix'. Its more that you are using an ultrasound. You should know where the tip of your needle is. You should take a picture of the wire inside the vessel etc. It just is something that is easily avoidable and yet it happens with seemingly increasing regularity.

The Cordis in the subclavian artery that our Pulm/CC fellows were running a special on a while ago (3 in a month)...now that's a little rougher...
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That is bad. lol

We've discussed this multiple times. It doesn't go over well politically with the medicine department at my institution.
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We've been slowly taking over all the lines in the hospital, which isn't a bad thing for us (kind of annoying getting the line consults, but whatever, its kinda what we do). But, those residents will have zero clue how to do them if they go to fellowship or elsewhere where they need to.
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southernIM said:
Oh I obviously completely agree. I've seen "senior" medicine residents "supervising" lines in the ICU when they've only put in 2 lines themselves. It's just not safe. But the fellows and attendings expect the residents to do them...so they do...

I can't even convince them to try transducing the venous pressure before they cannulate.

I've also seen a straight kill from a bedside procedure by a medicine resident...twice. That's pretty sobering.

I think the way to do it successfully at my institution would be to turn it into a multidisciplinary thing with all the specialties (medicine, anesthesia, surgery, EM) that do lines. But we don't have any buy-in for it at present.
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So how is it bad for someone to want to be proactive and learn to be competent at these procedures as early as possible? Seems like if schools make you do a medicine subI, there should be a procedural subI to at least try to reduce this issue...
 
mimelim said:
Last night I took a triple lumen out of a carotid (PGY3 IM). I'm currently waiting to inject a pseudoaneurysm with thrombin (Cards attending). Last week I had to stop an IM PGY2/intensivist after they shredded a wire putting in a quinton. I'm done tiptoeing about these avoidable complications. I'm a PGY2 (couple weeks from PGY3). I'm at the beginning of my training. From my position it has less to do with lack of experience and more to do with lack of good instruction and foundation. Nobody teaches good basics 🙁. In my infinite free time I'm trying to put together a course for non-surgical residents for basic bedside procedures.
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To be fair, very few medical students are doing procedures, which leads to not knowing the basics. I know your experiences differ from a lot of other students, but think of it as "Well, know you have people coming in your hospital with little to no procedure training...so now they have to learn from scratch!". Which, I'm sure can frustrate you given your stance on how students usually do tons of procedures where you are from, and now seeing that residents never even sutured in their life! I know the first time I really learned how to suture was intern year :O
 
southernIM said:
Oh I obviously completely agree. I've seen "senior" medicine residents "supervising" lines in the ICU when they've only put in 2 lines themselves. It's just not safe. But the fellows and attendings expect the residents to do them...so they do...

I can't even convince them to try transducing the venous pressure before they cannulate.

I've also seen a straight kill from a bedside procedure by a medicine resident...twice. That's pretty sobering.

I think the way to do it successfully at my institution would be to turn it into a multidisciplinary thing with all the specialties (medicine, anesthesia, surgery, EM) that do lines. But we don't have any buy-in for it at present.
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Those attendings should *gasp* teach the residents how to do them if they expect that. Or better yet, put them in rotations/workshops where they WILL learn it.

I was told in med school as a senior resident, on overnight call, I should be the one who would be expected to intubate or put in a central line, which scared me, since I've never done one in my life. The advice given was "Well, you'll learn as you go, or can ask an attending!", the attending who hasn't done one in 5-6 years! Thankfully, I know that to learn those, I had to learn it from people who do thousands of those(ED, surgery rotations) instead of experimenting around 😛
 
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VisionaryTics said:
Not too different from me. I would follow patients I admitted from triage, and I would usually pick up a few that were ready to pop when I came on. I only did like two cervical checks (with the infectious risk), but delivered about 10 babies vaginally and scrubbed on many more c-sections. I was only thrown out of the way once (when a shoulder dystocia occurred). I saw patients in triage, ultrasounded them, talked things over with the CNM, presented the patient, and wrote the notes.

You CAN get some involvement during third year. By contrast, a lot of my fellow med students on the same rotation/same location for OB did much less than I did. The difference? I stayed up on the L&D floor and did not sleep in the call room overnight. And I asked to do stuff.
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Our program uses two main hospitals (Big Tertiary Academic Center and Big Community Hospital) for its rotations, and unfortunately OB at Big Tertiary Academic Center is only high-risk OB. As a result, I didn't actually do a complete delivery by myself or even mostly by myself; I suppose I had my hands "in the game," but typically not for long as the resident would jump back in as soon as something didn't go perfectly. Understandable, for sure, but it made for a crappy learning experience. Most of the time was spent seeing triage patients (best one was the 15 y/o who was 5 months pregnant and didn't tell anyone prior to that visit) with a few procedures. In contrast, the students at Big Community Hospital had bread-and-butter OB (making it more amenable to student involvement) with high-volume and a week of nights. That seemed like a much better experience.
 
KnuxNole said:
To be fair, very few medical students are doing procedures, which leads to not knowing the basics. I know your experiences differ from a lot of other students, but think of it as "Well, know you have people coming in your hospital with little to no procedure training...so now they have to learn from scratch!". Which, I'm sure can frustrate you given your stance on how students usually do tons of procedures where you are from, and now seeing that residents never even sutured in their life! I know the first time I really learned how to suture was intern year :O
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I agree that fewer medical students are doing procedures which is a problem, but this isn't what I'm talking about here. I'm talking about the PGY2 - PGY30 who don't have basic technical capabilities who then try to do procedures or try to teach them. Not every doctor needs to know how to do those things. But, if you don't know or aren't going to learn, don't do them on patients. It has gotten to the point that I just gave the residents in the ICUs my number and told them that I'd be happy to do lines with them if I was free. Just set things up, text me and we'll talk through the basics. I don't even like gowning up, I'd rather just have an extra sterile set of gloves ready if necessary.

My point was that nobody should expect someone to be able to do procedures without being taught. But, at the same time, people need to recognize when what they are doing is dangerous. We aren't the police, we aren't here to tell people what they can and can't do. I feel like **** when I have a complication or something doesn't go as planned. I don't know how you can repeatedly have these kind of avoidable issues and not feel like you need to stop them from happening in the future.
 
NickNaylor said:
Our program uses two main hospitals (Big Tertiary Academic Center and Big Community Hospital) for its rotations, and unfortunately OB at Big Tertiary Academic Center is only high-risk OB. As a result, I didn't actually do a complete delivery by myself or even mostly by myself; I suppose I had my hands "in the game," but typically not for long as the resident would jump back in as soon as something didn't go perfectly. Understandable, for sure, but it made for a crappy learning experience. Most of the time was spent seeing triage patients (best one was the 15 y/o who was 5 months pregnant and didn't tell anyone prior to that visit) with a few procedures. In contrast, the students at Big Community Hospital had bread-and-butter OB (making it more amenable to student involvement) with high-volume and a week of nights. That seemed like a much better experience.
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which is why I'm doing surgical electives outside of my downtown city and in rural locations that I know let you do ****. I'll be done with the bull**** game of residency application by then. And, as I eluded to in the past, I'm not going to jump into intern year looking like an idiot...or try not to.
 
mimelim said:
I agree that fewer medical students are doing procedures which is a problem, but this isn't what I'm talking about here. I'm talking about the PGY2 - PGY30 who don't have basic technical capabilities who then try to do procedures or try to teach them. Not every doctor needs to know how to do those things. But, if you don't know or aren't going to learn, don't do them on patients. It has gotten to the point that I just gave the residents in the ICUs my number and told them that I'd be happy to do lines with them if I was free. Just set things up, text me and we'll talk through the basics. I don't even like gowning up, I'd rather just have an extra sterile set of gloves ready if necessary.

My point was that nobody should expect someone to be able to do procedures without being taught. But, at the same time, people need to recognize when what they are doing is dangerous. We aren't the police, we aren't here to tell people what they can and can't do. I feel like **** when I have a complication or something doesn't go as planned. I don't know how you can repeatedly have these kind of avoidable issues and not feel like you need to stop them from happening in the future.
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/agreed.
But I guess I don't know where you draw the line on "basic technical capabilities" that a resident should/shouldn't know. I've been told that a doctor should be competent in basic technical skills but then I agree with you in that they shouldn't go doing something they haven't been trained to do/know to do.

Meh. Medicine. F.cking medicine.
 
Internal Medicine should focus more on bedside procedures and less on circle jerking sessions called rounds. If you are working on a team, have x beds and keep your superiors well informed, what is the use for rounds?
Making sure that accesses are properly place and maintained and that nurses are doing their jobs is more important than discussing the metaphysical consequences of hypocalcaemia.
 
NickNaylor said:
Our program uses two main hospitals (Big Tertiary Academic Center and Big Community Hospital) for its rotations, and unfortunately OB at Big Tertiary Academic Center is only high-risk OB. As a result, I didn't actually do a complete delivery by myself or even mostly by myself; I suppose I had my hands "in the game," but typically not for long as the resident would jump back in as soon as something didn't go perfectly. Understandable, for sure, but it made for a crappy learning experience. Most of the time was spent seeing triage patients (best one was the 15 y/o who was 5 months pregnant and didn't tell anyone prior to that visit) with a few procedures. In contrast, the students at Big Community Hospital had bread-and-butter OB (making it more amenable to student involvement) with high-volume and a week of nights. That seemed like a much better experience.
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Funny would have thought the opposite experience based on this: http://theunderweardrawer.homestead.com/obgyn2.html
 
mimelim said:
I agree that fewer medical students are doing procedures which is a problem, but this isn't what I'm talking about here. I'm talking about the PGY2 - PGY30 who don't have basic technical capabilities who then try to do procedures or try to teach them. Not every doctor needs to know how to do those things. But, if you don't know or aren't going to learn, don't do them on patients. It has gotten to the point that I just gave the residents in the ICUs my number and told them that I'd be happy to do lines with them if I was free. Just set things up, text me and we'll talk through the basics. I don't even like gowning up, I'd rather just have an extra sterile set of gloves ready if necessary.

My point was that nobody should expect someone to be able to do procedures without being taught. But, at the same time, people need to recognize when what they are doing is dangerous. We aren't the police, we aren't here to tell people what they can and can't do. I feel like **** when I have a complication or something doesn't go as planned. I don't know how you can repeatedly have these kind of avoidable issues and not feel like you need to stop them from happening in the future.
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Where are you, exactly? I have to put the program I want to transfer into on one of these lines of this form...
 
NickNaylor said:
Our program uses two main hospitals (Big Tertiary Academic Center and Big Community Hospital) for its rotations, and unfortunately OB at Big Tertiary Academic Center is only high-risk OB. As a result, I didn't actually do a complete delivery by myself or even mostly by myself; I suppose I had my hands "in the game," but typically not for long as the resident would jump back in as soon as something didn't go perfectly. Understandable, for sure, but it made for a crappy learning experience. Most of the time was spent seeing triage patients (best one was the 15 y/o who was 5 months pregnant and didn't tell anyone prior to that visit) with a few procedures. In contrast, the students at Big Community Hospital had bread-and-butter OB (making it more amenable to student involvement) with high-volume and a week of nights. That seemed like a much better experience.
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At an academic medical center, I would think any prepartum patient there would be "high-risk". Surprised they didn't have bread-and-butter OB though. Of course, why would one go to a hospital do have your baby delivered by residents if you had the choice not to.
 
DermViser said:
At an academic medical center, I would think any prepartum patient there would be "high-risk". Surprised they didn't have bread-and-butter OB though. Of course, why would one go to a hospital do have your baby delivered by residents if you had the choice not to.
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What is with all the hate on OB/GYN residents doing their jobs (separate from their catty attitudes)?
 
Bacchus said:
I'm pretty sure I got a flyer in the mail advertising your avatar at resident pricing. Is that the UV light to scan for atypical cells?
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No, it's a dermatoscope. A fancy, handheld 10x magnifier with polarized light used to help identify features of specific lesions (melanocytic vs. nonmelanocytic, and myriad characteristics/findings to aid in diagnosis). Someone who is skilled with this device can greatly reduce the number of biopsies performed based on narrowing down pretest probability tremendously.
 
GuyWhoDoesStuff said:
No, it's a dermatoscope. A fancy, handheld 10x magnifier with polarized light used to help identify features of specific lesions (melanocytic vs. nonmelanocytic, and myriad characteristics/findings to aid in diagnosis). Someone who is skilled with this device can greatly reduce the number of biopsies performed based on narrowing down pretest probability tremendously.
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DermViser said:
LOL. No, it's a dermatoscope: http://en.wikipedia.org/wiki/Dermatoscopy
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Ha, ha. Jinx!
 
Kaustikos said:
which is why I'm doing surgical electives outside of my downtown city and in rural locations that I know let you do ****. I'll be done with the bullcrap game of residency application by then. And, as I eluded to in the past, I'm not going to jump into intern year looking like an idiot...or try not to.
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I don't understand, why would you want to "do ****"? I thought the point of rotations was to get out of them with a good score on the shelf exam while learning the least amount possible?
 
Arkangeloid said:
I don't understand, why would you want to "do ****"? I thought the point of rotations was to get out of them with a good score on the shelf exam while learning the least amount possible?
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Please PLEASE let this be sarcasm.
 
Arkangeloid said:
I don't understand, why would you want to "do ****"? I thought the point of rotations was to get out of them with a good score on the shelf exam while learning the least amount possible?
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I SO HOPE you are being sarcastic.
 
Arkangeloid said:
I don't understand, why would you want to "do ****"? I thought the point of rotations was to get out of them with a good score on the shelf exam while learning the least amount possible?
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That's how you become a ****ty doctor dude
 
Arkangeloid said:
No I'm serious...I'm confused 🙁
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Wow, ok. If you think the purpose of a clinical rotation is so that you can do well on a multiple choice NBME shelf exam and learn the least amount of clinical medicine possible, then you are wrong. Your score on an NBME shelf exam may make you still eligible for Honors, but it doesn't guarantee Honors, esp. if your clinical evaluations suck.

And before you ask, no, your knowledge of real clinical medicine/clinical judgement/clinical performance is not necessarily indicated by a shelf exam score.
 
DermViser said:
Wow, ok. If you think the purpose of a clinical rotation is so that you can do well on a multiple choice NBME shelf exam and learn the least amount of clinical medicine possible, then you are wrong. Your score on an NBME shelf exam may make you still eligible for Honors, but it doesn't guarantee Honors, esp. if your clinical evaluations suck.

And before you ask, no, your knowledge of real clinical medicine/clinical judgement/clinical performance is not necessarily indicated by a shelf exam score.
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Ah, I think I understand now.

I originally thought the purpose of a rotation was to prepare you for the shelf exam, which you studied for by yourself along with doing a bit of clinical work for it. That's why I was confused when the man above said he wanted to "do ****," because that would mean he had less time to study for the shelf exam, and would consequently get a lower score.
 
Arkangeloid said:
Ah, I think I understand now.

I originally thought the purpose of a rotation was to prepare you for the shelf exam, which you studied for by yourself along with doing a bit of clinical work for it. That's why I was confused when the man above said he wanted to "do ****," because that would mean he had less time to study for the shelf exam, and would consequently get a lower score.
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People's lives are going to be in your hands, dude.
 
Arkangeloid said:
Ah, I think I understand now.

I originally thought the purpose of a rotation was to prepare you for the shelf exam, which you studied for by yourself along with doing a bit of clinical work for it. That's why I was confused when the man above said he wanted to "do ****," because that would mean he had less time to study for the shelf exam, and would consequently get a lower score.
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He's doing MS-4 surgical electives (which don't have shelf exams), not a required MS-3 clerkship. The NBME shelf exam is not a blueprint for your clerkship. It is a standardized assessment measure. It's not the sole measure. It's hard for you to understand now bc you're still in the classroom as an MS-2 in which your entire mode of assessment (and self-worth) is based on multiple choice exams.
 
Arkangeloid said:
Ah, I think I understand now.

I originally thought the purpose of a rotation was to prepare you for the shelf exam, which you studied for by yourself along with doing a bit of clinical work for it. That's why I was confused when the man above said he wanted to "do ****," because that would mean he had less time to study for the shelf exam, and would consequently get a lower score.
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:laugh:

the man above
 
Wordead said:
People's lives are going to be in your hands, dude.
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Depends on the specialty. Psych and Path are examples, where that might not be the case.

I know people who loved studying, taking multiple choice exams and acing them but hated the actual daily grind of clinical medicine (long H&Ps, being on call, rounding, speaking with disgruntled family members, writing discharge summaries, etc.), so it's not completely unheard of.
 
DermViser said:
Depends on the specialty. Psych and Path are examples, where that might not be the case.

I know people who loved studying, taking multiple choice exams and acing them but hated the actual daily grind of clinical medicine (long H&Ps, being on call, rounding, speaking with disgruntled family members, writing discharge summaries, etc.), so it's not completely unheard of.
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It's still a really, really ****ty attitude to have. Even in those specialties.
 
Wordead said:
It's still a really, really ****** attitude to have. Even in those specialties.
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MS-3 clerkship grades can be gamed a lot, it's the nature of the beast. With Pathology, you can probably get away with that attitude. Psychiatry is relatively outpatient, low malpractice, good lifestyle so the frustrations are balanced off.

The ones I knew who hated clinical medicine usually hated the non-medicine, non-science related responsibilites of the job. For example, they loved reading about disease processes and pathogenesis in Harrison's, but couldn't stand having to actually talk and take care of patients for chronic problems that couldn't be solved. Reading it out of book gave them closure, while real life isn't as direct and tidy.
 
GuyWhoDoesStuff said:
I think he's talking about the resident discount on buying DermLites
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Oh ok, I didn't know he was a Derm resident buying a Derm Lite (unless maybe other residents buy it?). He had mentioned the flyer being a "UV light to scan for atypical cells". Our program gets it for us. Thanks for clearing that up.
 
DermViser said:
Oh ok, I didn't know he was a Derm resident buying a Derm Lite (unless maybe other residents buy it?). He had mentioned the flyer being a "UV light to scan for atypical cells". Our program gets it for us. Thanks for clearing that up.
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He's FM i think, but the company has been known to advertise to primary care too.

Our program buys ours, but I still get the occasional DL flyer in the mail.
 
DermViser said:
I SO HOPE you are being sarcastic.
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Does the information you learn on surgery, psych, obgyn translate if you KNOW you wanted to be an internist, for example? I know it's a **** attitude, but is there utility in being the best surgical med student if you won't use 99% of that knowledge again?
 
circulus vitios said:
Does the information you learn on surgery, psych, obgyn translate if you KNOW you wanted to be an internist, for example? I know it's a **** attitude, but is there utility in being the best surgical med student if you won't use 99% of that knowledge again?
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Why wouldn't it? It gives you a better understanding of when to refer a patient to another specialty and what they'll actually do when you do so. Also, maybe you won't have to refer the patient at all if it's a basic case and you can adequately treat them yourself.
 
ChEMD said:
Why wouldn't it? It gives you a better understanding of when to refer a patient to another specialty and what they'll actually do when you do so. Also, maybe you won't have to refer the patient at all if it's a basic case and you can adequately treat them yourself.
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Is the material one learns in 4 weeks in MS3 going to translate into actually treating a patient in real life and assuming the risks inherent to doing so? If it's that important, wouldn't it be emphasized in residency?
 
circulus vitios said:
Does the information you learn on surgery, psych, obgyn translate if you KNOW you wanted to be an internist, for example? I know it's a **** attitude, but is there utility in being the best surgical med student if you won't use 99% of that knowledge again?
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Absolutely. For instance, one of the most important things an internist can learn is who to consult when, and why.

Knowing how other specialties function (not to mention the obvious crossover between medicine and nearly every other field) is vital to an internal medicine physician's training and practice.
 
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