How much autonomy should an intern expect on inpatient psychiatry?

[psychthrowaway]

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Hey everyone,

Im looking to hear perspectives from other residents (and attendings ).

I’m on my last month of inpatient psychiatry of intern year (between three different institutions). I am on my second week of my rotation and am the only resident paired with one attending. For the most part, I watch her interview and then write the note. She makes med changes first thing in the morning making it hard for me to propose a plan. When I have asked her for opportunities to interview patients myself, she usually interjects and ends up driving the conversation. When I ask her for feedback, it’s always nonspecific but positive (usually that I have a nice bedside manner).

I am starting to feel like a very overeducated scribe. (I’m writing most of her notes). I am thinking either she hates how I interview but won’t give me constructive feedback or this is just how she is. For context as this is my last inpatient rotation, on my previous rotations I was able to gain autonomy from attendings as they gained trust in my interview skills/clinical judgement. I usually got to the point of seeing followups independently and staffing with attendings after. I have gotten very good feedback previously and “my milestone scores” are higher than my peers during my mid year review (if that even means anything).

Either way I am not learning very much and I want to change that. I’m looking for perspective on other people’s experiences. Did I have too much autonomy previously and now this is more appropriate for an intern? Or is this out of the normal and something I should, respectively, talk to her about? Thanks!

 

[bashir]

In my experience as an intern, inpatient attendings varied widely in the amount of autonomy they granted residents. It was certainly a recipe for frustration if one happened to get an attending who treats residents like med students later in the year after coming to expect some autonomy. It's a reflection of the attending's difficulty handing over responsibility, not of your performance. It's worth politely making it known you'd like more responsibility, but don't count on it changing anything. One month where you don't learn much is annoying, but isn't going to negatively impact your training enough to worry about. Come up with plans anyway, and if they differ substantially from the attendings, try to find out if you were missing something or if it's more of a style of practice thing. If you can't have these conversations with your current attending, run them by other attendings you trust who are invested in your learning. You can learn without autonomy. Don't get me wrong, though, it's natural to be frustrated.

 

[psychthrowaway]

In my experience as an intern, inpatient attendings varied widely in the amount of autonomy they granted residents. It was certainly a recipe for frustration if one happened to get an attending who treats residents like med students later in the year after coming to expect some autonomy. It's a reflection of the attending's difficulty handing over responsibility, not of your performance. It's worth politely making it known you'd like more responsibility, but don't count on it changing anything. One month where you don't learn much is annoying, but isn't going to negatively impact your training enough to worry about. Come up with plans anyway, and if they differ substantially from the attendings, try to find out if you were missing something or if it's more of a style of practice thing. If you can't have these conversations with your current attending, run them by other attendings you trust who are invested in your learning. You can learn without autonomy. Don't get me wrong, though, it's natural to be frustrated.

This is helpful. Especially in regards to making an effort to think of my own plans anyway and being a more active learner in that regard. Thanks!

 

[Monocles]

It absolutely varies based on attendings, and is usually no reflection of the intern's skill level/performance.

I've had attendings during pgy-1 year that basically says "go" and lets me do everything from family meetings to leading treatment teams, and attendings during pgy-2 years who will tell me what to document down to the specific dots and dashes because of their own neuroticism.

Residency can sometimes be more about surviving the difficult personalities (and I am not talking about the patients here haha)... and if you end up learning something out of the process then it's a bonus 😉

EDIT: also sometimes attendings just want to get work done as fast as possible so they can go home... which means doing their own 5 minute interviews with each patients, scribbling a bare minimum note and then going home. If you can prove to those attendings that having you involved will get them home sooner, they'll utilise you more. (whether or not this should be encouraged in an academic setting, is another discussion altogether)

 

[whopper]

IMHO attendings should give residents no autonomy until they've proven themselves competent. When dealing with residents where you don't know their skills you tell the residents you'll be double checking everything and you'll relax that based on their performance.

The worst resident for me other than a terrible resident was a good resident. Why? Cause if they're good they make you not want to double-check, and even good residents are green and will miss something sooner or later and then you as an attending are caught off-guard by the mistake cause you were letting them fly on autopilot too much.

Residency can sometimes be more about surviving the difficult personalities (and I am not talking about the patients here haha)... and if you end up learning something out of the process then it's a bonus 😉

I've ranted about this often. At my stage I feel as if I've surpassed most of the attendings who taught me and I say this not as a self-congratulatory comment but as a general comment that it shocks me the low bar I see among physicians. IMHO what I do should be standard and therefore average. I still remember the attending put in charge of ER psychiatry in my residency who was too chicken to kick out malingerers and let the nurses bully her. I remember 2 attendings that were pathetic and were that way in residency but they hired them after graduation cause the hospital needed psychiatrists and couldn't get anyone else. It wasn't until I was a professor at U of Cincinnati where I surrounded by great colleagues and the bar was where I thought it should be. Then when I left there cause of a move so my wife could get a job outside the area-same problem I had before.

To all of you residents who objectively (not narcisstically or egoistically) see your work as very good and notice colleague residents are lacking, these same guys will likely graduate. Residencies rarely kick out bad residents even when it's apparent they will not be good physicians. Medstudents have a false notion that all attendings are good. No. Many are terrible but were allowed to graduate and then practice. The bar for removing problematic residents and attendings...well look at it this way, the doctor who prescribed THE MOST amount of opioids in America and was clearly running a pill-mill did so for > 10 years despite that the writing was on the wall.....for years.

 

[MacDonaldTriad]

Residencies rarely kick out bad residents even when it's apparent they will not be good physicians.

whopper, you should put this in the "malignant programs" discussion. I agree with you.

 

[When is graduation again?]

IMHO attendings should give residents no autonomy until they've proven themselves competent. When dealing with residents where you don't know their skills you tell the residents you'll be double checking everything and you'll relax that based on their performance.

The worst resident for me other than a terrible resident was a good resident. Why? Cause if they're good they make you not want to double-check, and even good residents are green and will miss something sooner or later and then you as an attending are caught off-guard by the mistake cause you were letting them fly on autopilot too much.



I've ranted about this often. At my stage I feel as if I've surpassed most of the attendings who taught me and I say this not as a self-congratulatory comment but as a general comment that it shocks me the low bar I see among physicians. IMHO what I do should be standard and therefore average. I still remember the attending put in charge of ER psychiatry in my residency who was too chicken to kick out malingerers and let the nurses bully her. I remember 2 attendings that were pathetic and were that way in residency but they hired them after graduation cause the hospital needed psychiatrists and couldn't get anyone else. It wasn't until I was a professor at U of Cincinnati where I surrounded by great colleagues and the bar was where I thought it should be. Then when I left there cause of a move so my wife could get a job outside the area-same problem I had before.

To all of you residents who objectively (not narcisstically or egoistically) see your work as very good and notice colleague residents are lacking, these same guys will likely graduate. Residencies rarely kick out bad residents even when it's apparent they will not be good physicians. Medstudents have a false notion that all attendings are good. No. Many are terrible but were allowed to graduate and then practice. The bar for removing problematic residents and attendings...well look at it this way, the doctor who prescribed THE MOST amount of opioids in America and was clearly running a pill-mill did so for > 10 years despite that the writing was on the wall.....for years.

While I understand this thinking, it is frustrating as an intern to be treated as a glorified medical student on psych rotations. When we rotate through IM or Neuro, we're expected to evaluate and care for patients in medically tenious positions. Those attendings are present, but give us enough space to come up with plans and to take care of problems on our own without constantly micromanaging. Even my most directly involved IM attending was much more hands off than a chunk of psych attendings I've worked with this year.

In off service rotations, intern autonomy is expected, but for some reason in psych we have to fight for it. It's ridiculous. I think that's probably a large part of why a lot of psych attendings are subpar. I've worked with attendings and fellows that have had so little confidence managing patients and teaching residents/students, that I've genuinely wondered how they made it through residency and I suspect it is because they were never given (or expected) to have autonomy in caring for patients at any point in residency.

 

[DisorderedDoc417]

My experience would largely be restating what has been noted above. Some attendings give more autonomy and some give less. The former are better towards the end of the year, otherwise interns can feel overwhelmed, and the latter towards the beginning of the year to get their bearings. But... alas some will have it backwards and upside down from ideal. One thing I have appreciated is that when you repeatedly demonstrate competence and go out of your way to help the team, all attendings give you whatever they deem to be autonomy (degree again varies). If your program is anything like mine, you also get a little bit of the old benefit of the doubt when you’re through the internship and onto the remaining years for better or worse. Do your best, keep reading, and things will work out!

 

[Armadillos]

From your telling of it sounds like your view of the situation is probably accurate and your not getting the opportunity to manage your patients to the maximum extent of your abilities. That being said, sounds like you’ve had rotations where this isn’t this case so have gotten good training overall. Internship is long and tiring, maybe just enjoy a chill month and see what you learn along the way?

You could talk to other residents and see if they had same experience. If they did as well then is unlikely attending would suddenly change style and probably best to keep head down and make it through month without drama.

 

[FlowRate]

I've found that the actual structure of the unit can influence the degree to which residents can be autonomous.

If you have a short window to see patients on the unit and then go straight to a multidisciplinary team meeting as your daily form of rounding with the attending, it can be hard to come up with a new plan based on that day's presentation. This is what one of our units was like so the most autonomous I felt was work done and interventions suggested after that morning rush. Also, MD Team meetings are not a great venue (especially when also on a short time schedule) to be able to discuss differences in a plan and lend to attendings dictating the plan.

We also had attendings with pretty widely varying practice in regards to length of stay (partially related to which cases were directed to them, but not entirely.) This can make it tough to feel like you have the "right answer" with regard to when to discharge.