How to get more procedures in a busy academic center hospital?

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MedicineZ0Z

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Besides showing interest early on and trying to have procedure heavy rotations (ER, ICU) in the Spring (once everyone is signed off) is there any other tricks to it?

This being as a resident.
 
MedicineZ0Z said:
Besides showing interest early on and trying to have procedure heavy rotations (ER, ICU) in the Spring (once everyone is signed off) is there any other tricks to it?

This being as a resident.
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Display competency with your normal duties. And ask.

Then do a good job when given the opportunity
 
I’m just an M3, but I always try to tell my attendings and residents my goal is to get really good at ______ procedure by the end of whatever rotation I’m on.

They usually remember that and are happy to hand off that procedure when they come up later. Did this with I&Ds and Lac repairs and it worked great
 
It’s pretty easy as a resident because there are sooooooo many opportunities, plus you have the freedom to do pretty much any indicated bedside procedure you want. Want an arterial stick? Next ABG just DIY that sucker. Need an IV? Grab an ultrasound and put one in. There’s a lot of carryover from these to other procedures so it’s an easy way to build facility.

As for other stuff, I think expressing interest is key. Beyond that it’s knowing how to set up and demonstrating you know what you’re doing. You can tell fairly quickly who is truly comfortable doing something and it comes from how they set up and prepare. Make checklists or take pictures and really learn the setup so you look like an expert earlier on and attendings will tend to stand back and let you fly. Your seniors and attendings have a vested interest in getting you up to speed fast so they should be down with you developing your skills whenever possible.

Another trick is asking to do the thing that comes before the thing. Want to intubate? Ask to bag mask ( though ED and ICU do a lot more RSIs). Want to pop in a line? Ask if you can set up and then maybe find the vessels. This trick works like a charm because it puts you physically in position to do things right at the moment they need to happen. I’ve seen little MS3s get procedures using this trick and Lord knows I used it myself!
 
Thanks for the tips.

Would it help to have those rotations later in the year when residents in that specialty are signed off? My only concern was.. residents in their own specialty being given priority. At least until they hit their numbers.
 
operaman said:
You can tell fairly quickly who is truly comfortable doing something and it comes from how they set up and prepare. Make checklists or take pictures and really learn the setup so you look like an expert earlier on and attendings will tend to stand back and let you fly. Your seniors and attendings have a vested interest in getting you up to speed fast so they should be down with you developing your skills whenever possible.

Another trick is asking to do the thing that comes before the thing. Want to intubate? Ask to bag mask ( though ED and ICU do a lot more RSIs). Want to pop in a line? Ask if you can set up and then maybe find the vessels. This trick works like a charm because it puts you physically in position to do things right at the moment they need to happen. I’ve seen little MS3s get procedures using this trick and Lord knows I used it myself!
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High yield tips right here, thank you.
 
The best way to get procedures is to show you know what you’re doing. This means being accountable and confident in everything you do, not just procedures. I don’t care what month it is, if you’re in my ED and I think you are inept there’s no way I’m going to let you tube or line my patient.

If you haven’t already, watch YouTube videos on whatever procedure you need to learn. Then if you have a sim lab go there and practice it until it is boring. Usually all you have to do is call and schedule a time. Totally worth it because then you don’t have to worry about anyone else being there and you can just do whatever you want at your own pace. When asked if you’ve done one the answer is yes. Just don’t mention that fact that it was on someone made of plastic. Be sure to review any procedure on YouTube before you do them until you’ve done plenty. There is this stupid “watch one, do one, teach one” mantra in medicine that is so out of date it’s written in stone. Should be: YouTube one, do one, Facebook that you did one, make a YouTube video to teach one.

If you have any specific questions about any procedures I can answer them as well.
 
Tenk said:
The best way to get procedures is to show you know what you’re doing. This means being accountable and confident in everything you do, not just procedures. I don’t care what month it is, if you’re in my ED and I think you are inept there’s no way I’m going to let you tube or line my patient.

If you haven’t already, watch YouTube videos on whatever procedure you need to learn. Then if you have a sim lab go there and practice it until it is boring. Usually all you have to do is call and schedule a time. Totally worth it because then you don’t have to worry about anyone else being there and you can just do whatever you want at your own pace. When asked if you’ve done one the answer is yes. Just don’t mention that fact that it was on someone made of plastic. Be sure to review any procedure on YouTube before you do them until you’ve done plenty. There is this stupid “watch one, do one, teach one” mantra in medicine that is so out of date it’s written in stone. Should be: YouTube one, do one, Facebook that you did one, make a YouTube video to teach one.

If you have any specific questions about any procedures I can answer them as well.
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Great tips, thanks. And just as an add-on, if there's something I've done a lot of in med school (close to 100 intubations for example), is that something you make very well known; to get a shot at the very difficult tube patient?
 
MedicineZ0Z said:
Great tips, thanks. And just as an add-on, if there's something I've done a lot of in med school (close to 100 intubations for example), is that something you make very well known; to get a shot at the very difficult tube patient?
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I would. It’s not going to matter terribly much until you demonstrate competency but it’s worth mentioning when someone asks if you’ve done it before.

Unlikely you’re going to get a shot at the difficult one early on but you might as your residency progresses. Direct laryngoscopy is one of those procedures where you don’t really learn much from failed attempts other than to respect the difficult airway. You DO learn a lot from a tough look that you struggle with but manage to get. It’s hard to know in advance which ones this will be and I think we all tend to err on the side of letting the more experienced person take the tougher ones.

Here again you can demonstrate competence not only by skillfully doing the DL itself but also in your preparation and setup. Your preprocedure assessmemt of the airway is critical. Ditto your selection of laryngoscope based on the clinical scenario (it’s not always the video scope even though that’s a nice tool). Articulating this thought process as well as clearly communicating your backup plans is key to instilling confidence in your staff. Especially if you’re on an EM or ICU rotation, be able to recognize potential disasters and enlist the help of your in house difficult airway teams or have the patient taken to the OR for airway securement.

Once you’re actually DLing, communicating what you’re seeing is also key since absent a video scope you’re the only one with a view. Clearly saying the anatomy as you see it will keep your staffs’ BP down and let them know you aren’t lost yet even if it’s a tougher airway.
 
username456789 said:
Wut
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Yes. The OP was asking from a resident perspective. Obviously a student shouldn’t do that.

As the MD caring for that patient a resident can simply say that they’re going to get access. You don’t necessarily need an ultrasound but placing a peripheral IV under image guidance is very similar to placing lines under guidance. Great way to build your own skills especially on those tough sticks. I’ve never met anurse who didn’t mind a doc doing one for them. Every time I’ve done it I get about 5 other nurses asking if I’d put one in on their other patients!

The key point is that once you’re the MD you are helping direct their care and can be as hands on as you want within reason.
 
operaman said:
Yes. The OP was asking from a resident perspective. Obviously a student shouldn’t do that.

As the MD caring for that patient a resident can simply say that they’re going to get access. You don’t necessarily need an ultrasound but placing a peripheral IV under image guidance is very similar to placing lines under guidance. Great way to build your own skills especially on those tough sticks. I’ve never met anurse who didn’t mind a doc doing one for them. Every time I’ve done it I get about 5 other nurses asking if I’d put one in on their other patients!

The key point is that once you’re the MD you are helping direct their care and can be as hands on as you want within reason.
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I was just confused about needing an ultrasound to place an IV.

As an attending I’m never above doing tasks like that (or its analog in my field). That wasn’t the issue.
 
MedicineZ0Z said:
Great tips, thanks. And just as an add-on, if there's something I've done a lot of in med school (close to 100 intubations for example), is that something you make very well known; to get a shot at the very difficult tube patient?
Click to expand...

In general, if you can vocalise to me the indications for X procedure, your approach plan and your plan B then I don't have a problem giving you a shot at a procedure. Simply saying " I did 100 of X as a med student" when you're an off-service rotator isn't really impressive - if anything it's off putting and makes me think you aren't taking things seriously.
 
MedicineZ0Z said:
Great tips, thanks. And just as an add-on, if there's something I've done a lot of in med school (close to 100 intubations for example), is that something you make very well known; to get a shot at the very difficult tube patient?
Click to expand...
If asked, sure. That being said I’ve given exactly zero difficult airways to off service residents so if you’re in an ED with ED residents, I wouldn’t count on it.
 
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CherryRedDracul said:
It's better than having to throw in a central line for venous access. I used to these solo on night float when none of the nursing staff could get a good IV in.
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Again, I just don’t think of an ultrasound as necessary for IV access most of the time. Sure, there are some tough ones out there, but to suggest it as seemingly the default approach seems unwarranted and over the top.

Anyway, didn’t mean to totally derail the thread. I was just hoping clinical skills hadn’t fallen so far that students and residents learned to rely on ultrasound for most IVs.
 
username456789 said:
Again, I just don’t think of an ultrasound as necessary for IV access most of the time. Sure, there are some tough ones out there, but to suggest it as seemingly the default approach seems unwarranted and over the top.

Anyway, didn’t mean to totally derail the thread. I was just hoping clinical skills hadn’t fallen so far that students and residents learned to rely on ultrasound for most IVs.
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Given that the average american now has two inches of lard between their skin and their vasculature, it now has become necessary in alot of cases.

Personally, I don't put in nearly as many IVs as I did as a resident and med student, so if a nurse is asking for me to place one generally it's because the pt is a difficult stick, which has overall increased the rate of US guided IVs I place on a regular basis.
 
Tenk said:
If asked, sure. That being said I’ve given exactly zero difficult airways to off service residents so if you’re in an ED with ED residents, I wouldn’t count on it.
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How about other things like doing the primary survey on trauma (when they have atls already) or putting the chest tube in etc.
 
MedicineZ0Z said:
How about other things like doing the primary survey on trauma (when they have atls already) or putting the chest tube in etc.
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The only residents I’ve ever seen put in a chest tube in the ED have been ED residents and surgery residents. What specialty are you matching into?
 
Tenk said:
The only residents I’ve ever seen put in a chest tube in the ED have been ED residents and surgery residents. What specialty are you matching into?
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FM at my #2 but going into rural practice in my hometown where they also cover the ER and those procedural skills (airways, venous access, chest tubes) are of use. This center is friendly to FM in general though if that makes a difference.
 
MedicineZ0Z said:
No it's a large academic center lol. My #1 choice was unopposed.
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Yeah that might be a problem. If there are ER residents at that site, there's very little chance you're going to get many procedures, especially if there are interns on rotation with you.

OTOH, an extra ICU month or an anaesthesia elective could be fruitful
 
Lexdiamondz said:
Yeah that might be a problem. If there are ER residents at that site, there's very little chance you're going to get many procedures, especially if there are interns on rotation with you.

OTOH, an extra ICU month or an anaesthesia elective could be fruitful
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What about places that give off procedures to med students even when there are residents (this is one of those places)? I got a chest tube for example but the main pattern is spring time is when these procedures are handed off.
Also why isn't "your patient your procedure" a thing everywhere? The idea of another resident scooping in to do something for someone you assessed seems very silly to me.
 
MedicineZ0Z said:
What about places that give off procedures to med students even when there are residents (this is one of those places)? I got a chest tube for example but the main pattern is spring time is when these procedures are handed off.
Also why isn't "your patient your procedure" a thing everywhere? The idea of another resident scooping in to do something for someone you assessed seems very silly to me.
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Because ultimately that department’s priority is to train its own residents. An off service FM rotator does not necessarily need to know how to put in chest tubes, intubate or place CVLs.

At my shop the only procedures we split are trauma procedures w surgery. otherwise all procedures belong to residents as they should - our learning is paramount, period.
 
I think there are EM fellowships out of FM, no? This isn’t my area but I seem to recall that being mentioned as a possible option when I was a student. If you’re planning to work somewhere that you need these procedural skills, that’s one possible way to get it IF you aren’t able to get enough as a resident.

If you’re covering a rural ED back home I don’t think you necessarily need to be a true badass at all those things. There are plenty of EMTs that apparently intubate patients all the time so clearly that doesn’t take a dedicated residency to be able to stabilize and transfer people which is probably what you’ll do at a small rural hospital when anything airway and chest tube worthy rolls in the door. You may also find you get more experience than you realize as a resident. You will also get more practice once you’re out of training. It’s not like you only do what you learned in residency and never learn additional skills.
 
Fair. But perhaps affiliated community level II trauma ED electives? I think they have a site for their EM residents but they're only there half the year.
 
Lexdiamondz said:
Because ultimately that department’s priority is to train its own residents. An off service FM rotator does not necessarily need to know how to put in chest tubes, intubate or place CVLs.

At my shop the only procedures we split are trauma procedures w surgery. otherwise all procedures belong to residents as they should - our learning is paramount, period.
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No disagreement on the priorities (although I still think your patient your procedure should be a thing, and it is in many places). But it's a fact there are tons of ERs which give up intubations, CVLs and chest tubes to rotating students. Given that context, why is a stretch to give it to FM residents? I know there's a correct assumption that most FM residents have no interest and may even opt out. But if there is known interest and students are doing it too, then why not?
 
MedicineZ0Z said:
FM at my #2 but going into rural practice in my hometown where they also cover the ER and those procedural skills (airways, venous access, chest tubes) are of use. This center is friendly to FM in general though if that makes a difference.
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If you are actually planning to cover an emergency department as a FP attending you should really look into an ED fellowship although nothing will replace an EM residency. The chances of getting enough ED exposure this day and age in a regular family medicine residency is near zero. It was way different 30-40 years ago when ED volumes weren't bad, the technology wasn't there, the malpractice wasn't bad, and residents didn't have duty hours so they saw all kinds of crap and lived in the hospital.

Also, procedures are not the most important thing to master in EM. People flock to them because they are fancy but you are far more likely statistically to kill someone with a missed diagnosis than being unable to place a central line or intubate them. That's where the ED training really matters: volume and being able to differentiate sick from not sick.
 
Tenk said:
If you are actually planning to cover an emergency department as a FP attending you should really look into an ED fellowship although nothing will replace an EM residency. The chances of getting enough ED exposure this day and age in a regular family medicine residency is near zero. It was way different 30-40 years ago when ED volumes weren't bad, the technology wasn't there, the malpractice wasn't bad, and residents didn't have duty hours so they saw all kinds of crap and lived in the hospital.

Also, procedures are not the most important thing to master in EM. People flock to them because they are fancy but you are far more likely statistically to kill someone with a missed diagnosis than being unable to place a central line or intubate them. That's where the ED training really matters: volume and being able to differentiate sick from not sick.
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You're totally right in theory but shouldn't midlevels be killing people left and right since they have a tiny fraction of the ED exp and are virtually unsupervised in many settings?
 
MedicineZ0Z said:
You're totally right in theory but shouldn't midlevels be killing people left and right since they have a tiny fraction of the ED exp and are virtually unsupervised in many settings?
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ED midlevels are way more supervised than you think especially when starting out. They are trained by the attendings a lot of times like residents. Most only see level 4s and 5s as well so it is very very different.
 
MedicineZ0Z said:
You're totally right in theory but shouldn't midlevels be killing people left and right since they have a tiny fraction of the ED exp and are virtually unsupervised in many settings?
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It’s fairly uncommon for midlevels to be working in the ED unsupervised. The nature of the ED layout generally means you’re sitting in close proximity to an attending at all times and for the most part, mid levels are in fast track seeing ESI 4-5 typepatients suitable for urgent care.

As someone else mentioned, you’re going to be a physician held to the standard of a BCEM doctor if you work in an ED so your skill level needs to be higher for your own safety in addition to your patient’s
 
Lexdiamondz said:
It’s fairly uncommon for midlevels to be working in the ED unsupervised. The nature of the ED layout generally means you’re sitting in close proximity to an attending at all times and for the most part, mid levels are in fast track seeing ESI 4-5 typepatients suitable for urgent care.

As someone else mentioned, you’re going to be a physician held to the standard of a BCEM doctor if you work in an ED so your skill level needs to be higher for your own safety in addition to your patient’s
Click to expand...
Supervision is extremely variable from setting to setting. Also, in a lot of states the majority of docs in the ED are FP attendings. My point is, they can't be doing a terrible job if there's 0 evidence to show that they are. Also rural EDs carry less volume and hence it's easier to not miss things in comparison to a busy over run urban trauma center ED.

Anyway my point was if im doing my electives in ED, is it better to do them at affiliated community sites vs our level 1 center? For procedural exp and what not.
 
MedicineZ0Z said:
Anyway my point was if im doing my electives in ED, is it better to do them at affiliated community sites vs our level 1 center? For procedural exp and what not.
Click to expand...

Ask the people at your program. Talk to residents there. Get their experiences. Might have more insight than internet strangers would about an unnamed hospital/program
 
MedicineZ0Z said:
Supervision is extremely variable from setting to setting. Also, in a lot of states the majority of docs in the ED are FP attendings. My point is, they can't be doing a terrible job if there's 0 evidence to show that they are. Also rural EDs carry less volume and hence it's easier to not miss things in comparison to a busy over run urban trauma center ED.

Anyway my point was if im doing my electives in ED, is it better to do them at affiliated community sites vs our level 1 center? For procedural exp and what not.
Click to expand...
Evidence? The evidence is the fact that ABEM was created and FPs are being routed out of EDs continually every year. Most of the job recruitments I get require ABEM certification or eligibility. Many non board certified FPs are being reduced to doing locums work in hell holes.

There is this weird thing about the emergency department where other specialties think they can do my job (even better than me!). You can not do my job just like I can’t do a surgeon’s job or a cardiologist’s job or a family practitioner’s job. If you want to practice in an ED, do an EM residency. You don’t have to listen to me but I can guarantee you, if you work in any ED, there will come a day when some sick child or adult comes into your ED and the only thing you will have to fall back on will be your training which for a FP, is not much in terms of emergencies.
 
To avoid cremating the already long-dead horse lets avoid further discussion of whether or people not trained to do EM should be working in EDs.


To OP - we can't speak on the specifics of your programme but in general if you're at a place w EM residents you're not gonna get first dibs on procedures or even sick patients in general tbh. A community site may have lower acuity however if there aren't any residents you may have an easier time getting procedures you're interested in.
 
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