Intern year

[Idiopathic]

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Assuming I have to take a preliminary intern year, rather than match into a linked program, would it be better for me to do a medicine or a surgery internship? I would like to heard some opinions on why one would be better over the other.

 

[UTSouthwestern]

Assuming I have to take a preliminary intern year, rather than match into a linked program, would it be better for me to do a medicine or a surgery internship? I would like to heard some opinions on why one would be better over the other.

I would vote for a medicine internship. I feel that the exposure to complex medical pathology and the opportunity to rotate on pertinent services like pulmonology, cardiology, nephrology, and ICU provide you with a solid foundation of knowledge for anesthesiology. Your overall diagnostic skills would also be developed.

A surgical internship would increase your comfort level in the OR and probably give you more opportunity for procedures, but probably not to the level that would make it a deciding factor. Having said that, GS interns also have varying levels of OR time as well, so you may carry the bulk of the scut work for your team with less opportunities for the aforementioned scenarios. I recall a poster detailing his/her GS internship that sent chills down my spine.

My 2 cents worth.

 

[seattledoc]

I agree, medicine all the way. If you're a surgical intern and the program knows you're not going to stick around then it'll be a long year full of useless work. Not to say that a medicine residency won't do some of the same but it'll likely be combined with more learning of things pertinent to anesthesiology.

 

[CambieMD]

I would vote for a medicine internship. I feel that the exposure to complex medical pathology and the opportunity to rotate on pertinent services like pulmonology, cardiology, nephrology, and ICU provide you with a solid foundation of knowledge for anesthesiology. Your overall diagnostic skills would also be developed.

A surgical internship would increase your comfort level in the OR and probably give you more opportunity for procedures, but probably not to the level that would make it a deciding factor. Having said that, GS interns also have varying levels of OR time as well, so you may carry the bulk of the scut work for your team with less opportunities for the aforementioned scenarios. I recall a poster detailing his/her GS internship that sent chills down my spine.

My 2 cents worth.

I would think that a medicine internship would provide one with a better background. When I was in med school I remember some surgical interns hardly ever seeing the inside of an OR. A surgical internship may involve less crap but it seems that good wrking knowledge of some basic principals of IM
would make things easier later on.

CambieMD

 

[ThinkFast007]

take this with a grain of salt because i'm only a med student and i heard this from other med students. True what the above posters stated about GS might be true. However, with these 80 hr limits and most schools being very adherent to it (atleast mine is VERY VERY serious about it) surg prelim may not be that bad. Why? And i'm only a messenger so dont flame me...but as you know from your surgery rotation all they (surgeons) are concerned about for the most part is mgt (specifically surgery). As a result, all the 'brainwork' (medical issues) if you will, will likely be figured out by the medicine team already. Thus your life as a surgical intern would likely be easier. Maybe my school was different, but I actually saw this play out where i'm at. This is not to say that the surgical interns werent 'worked' but for the most part it seemed they were honed in on ONE or maybe TWO issues per pt and that was it, as opposed to medicine ppl.

👍
I guess it all boils down to what you want to get out of intern year.

 

[Mman]

I had a PD and a chair at 2 separate top anesthesia residencies strongly recommend getting as much medicine as possible in an intern year. That's what you are going to end up doing in the OR anyway. Might as well learn as much about the pathophysiology and treatment of the conditions of your patients as you can. Surgery interns get to focus on fluids, electrolytes, and working up a fever. Not terribly useful IMHO for anesthesia.

 

[cloud9]

As previous posts mention, the surgery intern may have varying levels of OR time. If Medicine sends chills down your spine chck various institutions to see what a surgery prelim year will allow you to do.

At my school, the intern does hardly any time in the OR (none I think but I'm not willing to be that absolute). The surgeons here insist that the intern prove themselves on the floor before they can do anything resembling the OR ("Every one wants to be a fighter pilot in their first year" I heard one faculty say during my clerkship 🙄 ). The two interns I worked with got no time in the OR during my clerkship. They were strictly floor or ER admit.

 

[VentdependenT]

Interesting take ThinkFast.

Although prelim medicine folks look peeved for the most part, if one clears house than one may sign out earlier. It always seems that the surg interns are getting creamed by all services. IM gets dumped on a lot but EVERYONE hastles surgery. Somebody has to touch the patient 😉 .

Just get some quality ICU/stepdown time and learn how to manage medical issues. There is more of the latter on IM along with exposure to pulm & cards electives. As a surg prelim one may still take charge o' blood pressure and sugars on surgery but once IM's on the case why bother. There are just to many consults and pages to handle. Management of fluids/lytes is inherent to both prelim years so no large discrepancy there and honestly its not all that difficult after some exposure.

The only advantage with surg year is that CA -1 year may sting less secondarily to having been exposed to the high levels of verbal and physical subjugation inherent to surgery. High pain threshold in otherwords. Also there is much more line placement but there is plenty o' that throughout the anesthesiologists' career.

No matter how one looks at it intern year is a tedious affair. The primary focus is on pushing bodies out the door and being a liason.

Transition year is the best option and if ANY of you have the opportunity to take one DO IT. In addition if you absolutely detest medicine then goen surg is a valid, if not harrowing, option. No matter what, find a group of folks you can hang out with and bitch about stuff to. Thats one of the best things about any internship/residency. Despite the pain there are plenty of laughs to be had.

 

[blocks]

We had an anesthesia-bound surgery intern on my service for surgery MS3 year. At this hospital prelim surg. was Q3 year round. Totally malignant program, the guy was clearly not loving it. He was kinda well known to roll the **** downhill to the med studs, I still felt really bad for him. It was June, and the guy had one week or so left, and he got a needle stick during a trauma code, multiple gunshots to the chest of a 19 year old gangbanger late, late at night. No kidding. I'm sure everything turned OK, but I will never forget him freaking out, cussing the hospital, the prelim year, his seniors, etc., drawing a syringe of blood out of the heart of this recently-deceased gangster s/p ED thoracotomy for an HIV test. Sure, worst case scenario, but that night pretty much sealed my decision for prelim medicine.

Great clerkship though.

 

[ThinkFast007]

Interesting take ThinkFast.

Although prelim medicine folks look peeved for the most part, if one clears house than one may sign out earlier. It always seems that the surg interns are getting creamed by all services. IM gets dumped on a lot but EVERYONE hastles surgery. Somebody has to touch the patient 😉 .

.

i just couldnt help but remember this when you mentioned 'touching' a pt. q time a female pt had ANY vag pain, d/c, or any remote ob issue...the surgeons always w/o a doubt consulted OB. The ob ppl would come down and check out the pt and be soooooooooo freakin pist cuz surgery didnt even bother to 'look' down there.

ahhh the of 'consulting' in academic institutions, sometimes i wonder if i'm in grade school playing 'hot potato'. 😉

 

[Frank Rizzo]

I had a PD and a chair at 2 separate top anesthesia residencies strongly recommend getting as much medicine as possible in an intern year. That's what you are going to end up doing in the OR anyway. Might as well learn as much about the pathophysiology and treatment of the conditions of your patients as you can. Surgery interns get to focus on fluids, electrolytes, and working up a fever. Not terribly useful IMHO for anesthesia.

I 2nd this. A number of PD's told me that they were glad to see that I was going to do a IM prelim. It can only help. There are exceptions to the rule, but Surg intern equals overworked robotic scutmonkey, transitional year intern equals glorified MS4, IM intern equals overworked, less-robotic scutmonkey. Try to find a nice community hospital... say Q5 call, with only overnight call being in the unit and on weekends, with plenty of lines and other small procedures to be had... They're out there... I found one

 

[me454555]

Idio and other DOs,

Are any of you guys worried that doing a medicine year instead of a traditional rotating internship will hurt you when it comes to liscensure those 4 states that require it or are you just planning on avoiding those states altogther?

 

[Goose...Fraba]

Idio and other DOs,

Are any of you guys worried that doing a medicine year instead of a traditional rotating internship will hurt you when it comes to liscensure those 4 states that require it or are you just planning on avoiding those states altogther?

I just posted a question about this in the general medical forums AMA vs. AOA, if I do end up doing a allo internship, I guess I'll just avoid those 5 states like the plague. I guess I'll repost my questoin again here, does anyone know if you took USMLE step I II & III as a DO, can you do a osteo internship and a allo residency? would you have to take the COMLEX III?

I guess the point of my question is I have heard from many DO attendings that getting CME credit in the osteo world is much harder than in the allo world, so they all have said to become a member of the AMA and a fellow of allo specialty boards in whatever I choose to do. that is why I am taking the usmle step II and III. Man I hope this makes sense, someone out there has got to know the answer, skip, anyone, someone!!!!!!

 

[VentdependenT]

I just posted a question about this in the general medical forums AMA vs. AOA, if I do end up doing a allo internship, I guess I'll just avoid those 5 states like the plague. I guess I'll repost my questoin again here, does anyone know if you took USMLE step I II & III as a DO, can you do a osteo internship and a allo residency? would you have to take the COMLEX III?

I guess the point of my question is I have heard from many DO attendings that getting CME credit in the osteo world is much harder than in the allo world, so they all have said to become a member of the AMA and a fellow of allo specialty boards in whatever I choose to do. that is why I am taking the usmle step II and III. Man I hope this makes sense, someone out there has got to know the answer, skip, anyone, someone!!!!!!

That is a good question and I don't know the answer. I'll be taking COMLEX III under the assumption that upon completion of an allopathic residency with allo boards certification that allo CME for my specialty would suffice. After all its the ABA boards which I have to pass in order to be licensed. I would think that CME = CME wheather its osteopathic or allopathic.

I'll ask my PD, its something I really haven't thought about. Quinn would probably know too.

 

[Goose...Fraba]

That is a good question and I don't know the answer. I'll be taking COMLEX III under the assumption that upon completion of an allopathic residency with allo boards certification that allo CME for my specialty would suffice. After all its the ABA boards which I have to pass in order to be licensed. I would think that CME = CME wheather its osteopathic or allopathic.

I'll ask my PD, its something I really haven't thought about. Quinn would probably know too.

Just to further explain...

I did a rotation with a DO ENT. Sometimes we would go to afternoon lunch lectures, where attendings are supposed to get 1 CME credit. anyways, he went on about how this only counts as catagory 2 in the AOA, whereas a MD in the same lecture will get catagory 1 credit, or something to that effect. he went on to say that every couple of years he has to attend the AOA conference just to get enough catagory 1 credit to maintain licensure. at the AOA conference he gets lectured about freakin hypertension and stuff not related to ENT at all. Anyways he said to me if I had the option to try to do all allo stuff so that if I was say an ER doc, I could go to the ABEM CME courses and get credit. I dont know if this further complicates my original question or clarifies it.

 

[gaspasser2004]

I'm going to have to go with the majority here on this one - prelim medicine is the best in my opinion. There is no other internship where you have more responsibility over your patients. As a medicine intern, you admit patients essentially as the primary physician, work them up, order consults etc and see them through the hospital course. Obviously you don't know enough medicine to make all the decisions on the patients, but good programs let only residents write orders, so all decisions eventually flow through your orders.

Nearing the end of my internship, I am very comfortable managing patients and making decisions about their care. On call, I make the decisions regarding acute management of my patients and the patients I cover. In two months, I'll be alone in the OR doing the same. Obviously, help is available in both situations, but I am already used to the autonomy.

As a surgical intern, you are a cog on the wheel of the surgical machinery. Scut scut scut. Any OR time you do receive is a revisitation of MSIII days of holding retractors. Sure, the categorical interns may do some cool stuff, but most programs won't let the prelims do crap.

A transitional intern is, as previously posted, a glorified MSIV. You bounce from service to service not truly getting a strong grasp on patient care and never fully trusted by the managing team.

I'll be honest, I haven't done many procedures in my prelim medicine year. Am I concerned? No. If I knew how to put in lines, intubate, etc already, I wouldn't need to to a residency in anesthesiology.

 

[2ndyear]

I'm sure that the IM year is great for preparation. I did the transitional route. As far as the other services not trusting a TY year as much, this isn't always true. Where I'm at, the medicine and peds residents are sooo unbelieveably weak that we TY interns are held in very high regard by the primary service. I would imagine other community programs are similar. IM and peds are dime a dozen in the community, and they simply can't get quality people into them.

Also, TY years vary in how much IM you do. Mine is only 2 floor months, some are 6 though.

 

[VentdependenT]

I'm sure that the IM year is great for preparation. I did the transitional route. As far as the other services not trusting a TY year as much, this isn't always true. Where I'm at, the medicine and peds residents are sooo unbelieveably weak that we TY interns are held in very high regard by the primary service. I would imagine other community programs are similar. IM and peds are dime a dozen in the community, and they simply can't get quality people into them.

Also, TY years vary in how much IM you do. Mine is only 2 floor months, some are 6 though.

2 floors
1 nightfloat
1 Progressive Coronary Care Unit
1 MICU
1 ID, Cards, Pulm,
Thats enough medicine for me this year.
On top of that EM (plenty o' autonomy) and Rads. Both pretty cool.

I enjoyed my TY and felt that although I could have been worked harder, by having less electives and more call at a prelim med program, I feel pretty well rounded. I will admit that on my 2 weeks of path right now I'm feeling the 4th year business, but it definitely could be worse. 🙂

 

[M]

I'm sure that the IM year is great for preparation. I did the transitional route. As far as the other services not trusting a TY year as much, this isn't always true. Where I'm at, the medicine and peds residents are sooo unbelieveably weak that we TY interns are held in very high regard by the primary service. I would imagine other community programs are similar. IM and peds are dime a dozen in the community, and they simply can't get quality people into them.

Also, TY years vary in how much IM you do. Mine is only 2 floor months, some are 6 though.

I had the same experience. The senior IM residents told us many times that they trusted us more than the IM interns. We were given more responsibilities and our decisions weren't questioned as much. In all fairness, I think it was just a bad year for the IM program. Three of the categoricals wound up switching to a different specialty.

I am going to add another vote for the TY. I had a great year that consisted of 3 floor months, 1 ICU month, 3 1/2 months of General/Vascular/Orthopaedic Surgery (by choice), 1 month of EM, 1 month of Neuroradiology, 1 1/2 months on the Pain service, and 1 month for vacation. I could've done more medicine if I really wanted to.

 

[hawkdoc05]

I won't be doing any anesthesia months during my intern year next year. Will that make a huge difference? My program's categorical interns will have 2 months under their belt by the time I show up for orientation. Thanks for any replies.

 

[sublimazerules]

I won't be doing any anesthesia months during my intern year next year. Will that make a huge difference? My program's categorical interns will have 2 months under their belt by the time I show up for orientation. Thanks for any replies.

I'm in the same boat, so I asked about it. Both the PD at my school and the PD of the program I matched at said it was no big deal.....that maybe I would be a little "behind" for the first 2 weeks or so, but that I would soon catch up. The learning curve is so steep early in your anesthesia training that it really doesn't matter all that much. I totally stopped worrying about it. 😎

 

[VentdependenT]

Just to further explain...

I did a rotation with a DO ENT. Sometimes we would go to afternoon lunch lectures, where attendings are supposed to get 1 CME credit. anyways, he went on about how this only counts as catagory 2 in the AOA, whereas a MD in the same lecture will get catagory 1 credit, or something to that effect. he went on to say that every couple of years he has to attend the AOA conference just to get enough catagory 1 credit to maintain licensure. at the AOA conference he gets lectured about freakin hypertension and stuff not related to ENT at all. Anyways he said to me if I had the option to try to do all allo stuff so that if I was say an ER doc, I could go to the ABEM CME courses and get credit. I dont know if this further complicates my original question or clarifies it.

I ran it by Quinn and some other DOH's who are doing ACGME residencies and it seems that we no longer have to bend under the mighty will of the AOA. You deal with the governing body in charge of your specialty. For us, I believe it would be this esteemed group of individuals: http://www.asahq.org/continuinged.htm.

Your buddy got screwed, sorry.

 

[IceDoc]

I would vote for a medicine internship. I feel that the exposure to complex medical pathology and the opportunity to rotate on pertinent services like pulmonology, cardiology, nephrology, and ICU provide you with a solid foundation of knowledge for anesthesiology. Your overall diagnostic skills would also be developed.

A surgical internship would increase your comfort level in the OR and probably give you more opportunity for procedures, but probably not to the level that would make it a deciding factor. Having said that, GS interns also have varying levels of OR time as well, so you may carry the bulk of the scut work for your team with less opportunities for the aforementioned scenarios. I recall a poster detailing his/her GS internship that sent chills down my spine.

My 2 cents worth.

Agree with above. Would add an incident where an Anes resident who did a surgical internthip had a pt go into Afib RVR in the recovery room. Unfortunately he had no idea what to do. Apparantly he didn't learn how to take care of that during his surgical year.

However, if there is ANY CHANCE you MIGHT change your mind and go into surgery instead of anesthesia, then by all means do the surgical internship!

 

[barkster]

My brother-in-law is in his first year out from residency. He did surgery and recommended it. He said that first of all, you learn how surgeons think and operate (pun sort of intended). He says that helps him to be a better anesthesiologist. He also told me he got to do a lot of procedures, and as a result, he was and still is more comfortable than some of his counterparts at certain procedures.

I still don't know what I'm going to do, but I just thought I'd offer another opinion.

 

[jetproppilot]

Assuming I have to take a preliminary intern year, rather than match into a linked program, would it be better for me to do a medicine or a surgery internship? I would like to heard some opinions on why one would be better over the other.

Ever consider a transitional year? My residency had the PGY-1 year connected, which was a transitional internship- 3 mos medicine, 3 mos ER (medicine, trauma, pedi, 1 month each) 2 months surgery, and 4 mos electives- i did derm, path, cardiology, and something else I cant remember now.
What really made me a better doctor was the amount of moonlighting I did- as soon as I got my license and DEA# I worked in an ER 2 or 3 weekends a month ( 2 twelve hour shifts) for the three years of anesthesia residency- did and saw just about everything you can do in an ER. Helps me to this day.

 

[timtye78]

dont tell some of the others on SDN a non-EM residency trained licensed physician has worked in the ED. According to some, you are endangering patients!

BTW, I think any licensed MD/DO should be able to moonlight in ED

 

[UTSouthwestern]

dont tell some of the others on SDN a non-EM residency trained licensed physician has worked in the ED. According to some, you are endangering patients!

BTW, I think any licensed MD/DO should be able to moonlight in ED

I will say that all of the ER's I have moonlighted in were delighted to have an anesthesiologist available for the crash and burn patients. In the suburban and rural ER's, you may be the one putting in chest tubes and the like.

If you are going to moonlight in an ER, even one that is not level one, please get ATLS certification on top of ACLS/PALS.

 

[sublimazerules]

My brother-in-law is in his first year out from residency. He did surgery and recommended it. He said that first of all, you learn how surgeons think and operate (pun sort of intended). He says that helps him to be a better anesthesiologist. He also told me he got to do a lot of procedures, and as a result, he was and still is more comfortable than some of his counterparts at certain procedures.

I still don't know what I'm going to do, but I just thought I'd offer another opinion.

Was your brother-in-law at a community program?? Because from what I've seen at my school, surgery interns don't do any procedures besides central lines and the occasional I&D or herniorraphy.......and that's for the categorical interns. If you're prelim, you're a scutmonkey and most of your patient contact involves asking people whether they've pooped or not. From what I've heard, though, the experience at a community program is much different.

 

[Laryngospasm]

Assuming I have to take a preliminary intern year, rather than match into a linked program, would it be better for me to do a medicine or a surgery internship? I would like to heard some opinions on why one would be better over the other.

Prepare for some serious scut work if you do a surgery internship 😀

 

[hoyden]

11

 

[powermd]

Actually, an intimate understanding of heart failure, arrhythmias, and respiratory disease, especially as it presents in the CCU/MICU setting is probably very useful knowledge for someone who will be titrating fluids, blood products, pressors, and diagnosing/treating arrhythmias in the OR or PACU when one of these patients requires surgery.

You can make a joke that some of the activities in IM are irrelevant to anesthesia, but the reality is likely that a thorough understanding of internal medicine is more useful preparation of anesthesiology than surgery (which you will get every day for your entire career).

 

[powermd]

Actually, an intimate understanding of heart failure, arrhythmias, and respiratory disease, especially as it presents in the CCU/MICU setting is probably very useful knowledge for someone who will be titrating fluids, blood products, pressors, and diagnosing/treating arrhythmias in the OR or PACU when one of these patients requires surgery.

You can make a joke that some of the activities in IM are irrelevant to anesthesia, but the reality is likely that a thorough understanding of internal medicine is more useful preparation for anesthesiology than surgery (which you will get every day for your entire career).

 

[powermd]

Really?!?I guess titrating NPH insulin in elderly diabetics with HTN, CHF and COPD is much more useful. FOR ANESTHESIA.

Actually, an intimate understanding of heart failure, arrhythmias, and respiratory disease, especially as it presents in the CCU/MICU setting is probably very useful knowledge for someone who will be titrating fluids, blood products, pressors, and diagnosing/treating arrhythmias in the OR or PACU when one of these patients requires surgery.

You can make a joke that some of the activities in IM are irrelevant to anesthesia, but the reality is likely that a thorough understanding of internal medicine is more useful preparation for anesthesiology than surgery (which you will get every day for your entire career).

 

[barkster]

Was your brother-in-law at a community program?? Because from what I've seen at my school, surgery interns don't do any procedures besides central lines and the occasional I&D or herniorraphy.......and that's for the categorical interns. If you're prelim, you're a scutmonkey and most of your patient contact involves asking people whether they've pooped or not. From what I've heard, though, the experience at a community program is much different.

He was at a large academic program. Actually, now that I think about it, I think he did 2 years of surgery. He started off doing surgery, then switched to anesthesia. So he probably got a lot of procedural experience in his 2nd year. Sorry, I didn't mean to mislead you. Totally forgot he did 2 years...

 

[hoyden]

11

 

[GasEmDee]

I guess there is no need to underline, how serious you are - NO JOKING, AT ALL; otherwise you'd never post the same text thrice?

As to the fact about deep understanding of arrhythmias and respiratory disease, I've always thought that intern year starts after finishing medical school, not before it.

Anyway, I, personally, tend to beleive IM is not a better choice for the intern year and my intern year is actually transitional with only 3 months of surgery and none of the IM, which is great for me. Every one else is free to chose whatever he/she feels fits better.

But I still feel somebody's opinion that learning how to calculate fluids is not valuable for future anesthesiologist is worth teasing it.

Just IMHO 😀

Well, some of the giants in the world of anesthesia would disagree quite strongly with you. Ron Miller, for example, strongly favors the medicine prelim year. To be fair, he also sees anesthesia taking a much larger role in the critical care arena, whereas not everyone else feels that the field should move in this direction.

Incidently, I hear that in the near future, most anesthesia residencies will be transitioning to integrated programs that include the internship year. My understanding is that this internship year will include lots of medicine and ICU.

And as for a deep understanding of the material, i dont really think med school rotations compare to the internship experience...but thats me.

 

[UTSouthwestern]

Well, some of the giants in the world of anesthesia would disagree quite strongly with you. Ron Miller, for example, strongly favors the medicine prelim year. To be fair, he also sees anesthesia taking a much larger role in the critical care arena, whereas not everyone else feels that the field should move in this direction.

Incidently, I hear that in the near future, most anesthesia residencies will be transitioning to integrated programs that include the internship year. My understanding is that this internship year will include lots of medicine and ICU.

And as for a deep understanding of the material, i dont really think med school rotations compare to the internship experience...but thats me.

2008 is the magic year for that transition to integrated residencies. By that time, 6 months of critical care will have to be integrated into the four year residency. Pain management requirements will also likely be standardized.

These moves are being made to increase our presence in these fields as well as to provide more experience in fields that our background and training should make us suitable for.

 

[toughlife]

2008 is the magic year for that transition to integrated residencies. By that time, 6 months of critical care will have to be integrated into the four year residency. Pain management requirements will also likely be standardized.

These moves are being made to increase our presence in these fields as well as to provide more experience in fields that our background and training should make us suitable for.

That's nice to hear. It would be good to train future MDAs to be be able to do more CC. While on this topic, I am wondering if you would mind shedding some light on how a MDA is different from a pulmonary doc when it comes to running the ICU. An attending at my school said that an MDA could not be in charge of a MICU but I am not sure I believe him.

 

[2ndyear]

That's nice to hear. It would be good to train future MDAs to be be able to do more CC. While on this topic, I am wondering if you would mind shedding some light on how a MDA is different from a pulmonary doc when it comes to running the ICU. An attending at my school said that an MDA could not be in charge of a MICU but I am not sure I believe him.

Not true, it's a one year fellowship after anesthesiology residency, just like it's a one year fellowship after internal medicine or surgery. Those are the 3 specialties that do CCM fellowships. The pulmonary docs do 3 years fellowship but some of that is pulmonology as well. EM physicians can do fellowships as well though it's a muddy area right now as I undertand it.

 

[dbiddy808]

It is two years after Internal Medicine.

 

[sweep arpeggio]

As a soon to be attending, I can tell you that my very malignant IM year was a tremendous help to me during my clinical anesthesiology training. An anethesiologist is essentially an internist in the operating room, and a solid backround in pulmonary medicine and cardiology makes things much easier. And in those months of ICU, your general medicine, infectious disease and nephrology training puts you miles ahead of where you would be had you been a surgical intern.

Yes, as a surgical intern in most places you will get more experience with lines, but that is a skill you will get a LOT of practice at in your anesthesia training, especially if your program has decent cardiac experience. The main thing you need to do during your intern year is to learn how to think critically and logically. Instead of worrying about what's "easier", start thinking about how what you are going to do is going to prepare you fro the challenges of anesthesia practice. The unfortunate reality is that we are seeing and will continue to see a patient population that is sicker and sicker.

 

[UTSouthwestern]

That's nice to hear. It would be good to train future MDAs to be be able to do more CC. While on this topic, I am wondering if you would mind shedding some light on how a MDA is different from a pulmonary doc when it comes to running the ICU. An attending at my school said that an MDA could not be in charge of a MICU but I am not sure I believe him.

Not true. There are a couple of private hospitals in Dallas with MDA's in charge of MICU's. I believe that pulmonologists are pushing to keep more control of MICU's but I don't think they have to worry about a flood of MDA's trying to take over the MICU's of this country.

 

[jimdoc]

I am very surprised by all of these folks raving for a prelim medicine year. At my program, 4 of us were transfers from GS. There was a tremendous difference in our competencies when we first started. I was at a community program, q3. I operated nearly everyday and logged over 400 OR cases( did more like 500-600.) Close to 100 central lines and probably about the same a-lines,50-60 PA catheters.... and in my 6 weeks of thoracic probably 40-50 chest tubes. I did lots of trachs, as well as a lots of trauma experience....As well, you know what to expect in the OR. There is really no intimidation from the surgeons from day 1 because of this.

In terms of medical management.....I typically covered 30+ patients per night with just a chief as back up....these patients all had medical issues which I dealt with. Many of these issues were post surgical issues as well, which is what you will deal with as an anesthesiologist. I did 2 months of ICU and one of cardiac ICU, which, from my experience the SICU/CTICUs are light years ahead of the medical ICU's. My hours were about 110 per week, but now this I am sure has changed.

I would not however do a prelim surgical year at a big academic powerhouse...lots and lots of scut, no operative time. My communnity program was extremely efficient, and I never once drew a lab or blood culture other than an ABG. 4 out of 5 days I operated from 7-4/5. I have talked about this with some of my anesthesia attendings, and the other guys who switched out of GS. Everyone agrees the GS folks are months ahead of the medicine folks. As well, the pace of anesthesiology is more in line with GS than medicine.....You must know physiology and be able to think, but you must also be willing to come to a diagnosis quickly and take decisive action........take my word for it, do GS at a community program, it will actually be fun, efficient, and put you months ahead...I laugh now when I see the first year anesthesia residents trying to put a radial line or central line in during their first few months....remember, those a-lines need to go in quickly as possible....line your patients up quickly as a CA-1 and your peeps will be impressed......

 

[JudoKing01]

It's not just the CA-1s that take forever sometimes. Most of the anesthesiologists I've been around (this is only at two hospitals, so don't flame) take sometimes longer than the whole operation to put an a-line in. There were a few times where we waited a good 30-45 minutes while the attendings tried to intubate fiberoptically, only to have the CRNA do it with a blade in 3 seconds while the ologist was fuddling with something else.

This isn't meant as an insult to anesthesia...actually, after being on this forum for only a few days I am much more interested in going into anesthesia after med school. It seems like a great field.

 

[UTSouthwestern]

I am very surprised by all of these folks raving for a prelim medicine year. At my program, 4 of us were transfers from GS. There was a tremendous difference in our competencies when we first started. I was at a community program, q3. I operated nearly everyday and logged over 400 OR cases( did more like 500-600.) Close to 100 central lines and probably about the same a-lines,50-60 PA catheters.... and in my 6 weeks of thoracic probably 40-50 chest tubes. I did lots of trachs, as well as a lots of trauma experience....As well, you know what to expect in the OR. There is really no intimidation from the surgeons from day 1 because of this.

In terms of medical management.....I typically covered 30+ patients per night with just a chief as back up....these patients all had medical issues which I dealt with. Many of these issues were post surgical issues as well, which is what you will deal with as an anesthesiologist. I did 2 months of ICU and one of cardiac ICU, which, from my experience the SICU/CTICUs are light years ahead of the medical ICU's. My hours were about 110 per week, but now this I am sure has changed.

I would not however do a prelim surgical year at a big academic powerhouse...lots and lots of scut, no operative time. My communnity program was extremely efficient, and I never once drew a lab or blood culture other than an ABG. 4 out of 5 days I operated from 7-4/5. I have talked about this with some of my anesthesia attendings, and the other guys who switched out of GS. Everyone agrees the GS folks are months ahead of the medicine folks. As well, the pace of anesthesiology is more in line with GS than medicine.....You must know physiology and be able to think, but you must also be willing to come to a diagnosis quickly and take decisive action........take my word for it, do GS at a community program, it will actually be fun, efficient, and put you months ahead...I laugh now when I see the first year anesthesia residents trying to put a radial line or central line in during their first few months....remember, those a-lines need to go in quickly as possible....line your patients up quickly as a CA-1 and your peeps will be impressed......

It's been the opposite here with the medicine guys doing better. The pace is something that you can pick up quickly. It took me a couple of weeks to get adjusted to being in the OR per se, but after that I was off and running. The GS guys all came from big programs so as you said, the scut was what dominated their lives.

Suprisingly, though, our medicine guys, myself included, have done as many chest tubes (pulmonary, cardiac, and ER rotations), central lines, a-lines, intubations, etc. as some of the GS guys including the 2 and 3 year transfers from good programs like UCSF, UCSD, and our own GS program. Not too shabby for medicine docs.

 

[jimdoc]

No way as a medicine intern you did over 100 central lines....(this is conservative estimate). Now I often get called into the MICU for tough central lines/ intubations/ pa catheters...even at a top 10 hospital with pulmonary fellows...these guys stumble still, and i have NEVER seen a medicine intern or chief put in a cordis.......perhaps those surgical residents were foreign grads they often make do a surgical residency, or perhaps there were at a ploace like where here where only the cardiac fellows place chest tubes....Only surgical residents or cardiology fellows were allowed to float a PA catheter, so in the middle of the might, i would have to go to the MICU as an INtern, while the medicine chief watched me because the card fellow was at home.
My surgical ICU months/cardiac months as an anes resident were very easy...except for the LVAD patients......
In the ORI, I often felt more competent than the younger anesthesia attendings placing a cordis my first month of anesthesia residency, certainly better than most of the CA-3 residents I had done more of them.....I have no problem dropping a subclavian if I can't get the IJ, as well as all of the trauma experience....

This is my experience only, but if you go to a good community program, you will have lots of PA's, efficiency is a must, these place are in the profit business....I only did discharge summaries on weekends. Yes, even whe there were no hour limitations, it was fun.....If you are assertive, you will operate a lot..I still feel like I could kick the PGY-4's ass on a lap chole here....They just don;'t do enough because we have laparoscopic fellows.......

my two cents, but who the F*#& wants to spend half the day rounding....absolute torture. with the 80 hour work week, and going home post call, there is no way I would do a medicine internship.......Like I said, my internship was actually kind of fun.....even at 110+ some weeks.

 

[toughlife]

No way as a medicine intern you did over 100 central lines....(this is conservative estimate). Now I often get called into the MICU for tough central lines/ intubations/ pa catheters...even at a top 10 hospital with pulmonary fellows...these guys stumble still, and i have NEVER seen a medicine intern or chief put in a cordis.......perhaps those surgical residents were foreign grads they often make do a surgical residency, or perhaps there were at a ploace like where here where only the cardiac fellows place chest tubes....Only surgical residents or cardiology fellows were allowed to float a PA catheter, so in the middle of the might, i would have to go to the MICU as an INtern, while the medicine chief watched me because the card fellow was at home.
My surgical ICU months/cardiac months as an anes resident were very easy...except for the LVAD patients......
In the ORI, I often felt more competent than the younger anesthesia attendings placing a cordis my first month of anesthesia residency, certainly better than most of the CA-3 residents I had done more of them.....I have no problem dropping a subclavian if I can't get the IJ, as well as all of the trauma experience....

This is my experience only, but if you go to a good community program, you will have lots of PA's, efficiency is a must, these place are in the profit business....I only did discharge summaries on weekends. Yes, even whe there were no hour limitations, it was fun.....If you are assertive, you will operate a lot..I still feel like I could kick the PGY-4's ass on a lap chole here....They just don;'t do enough because we have laparoscopic fellows.......

my two cents, but who the F*#& wants to spend half the day rounding....absolute torture. with the 80 hour work week, and going home post call, there is no way I would do a medicine internship.......Like I said, my internship was actually kind of fun.....even at 110+ some weeks.

So what would be your advice in choosing a prelim surg program?

What criteria should I look for to decide if the program will have opportunities to learn as many procedures as possible?

I am applying this year and still trying to decide which prelim year to go for.

Your advice would be appreciated.

 

[UTSouthwestern]

No way as a medicine intern you did over 100 central lines....(this is conservative estimate). Now I often get called into the MICU for tough central lines/ intubations/ pa catheters...even at a top 10 hospital with pulmonary fellows...these guys stumble still, and i have NEVER seen a medicine intern or chief put in a cordis.......perhaps those surgical residents were foreign grads they often make do a surgical residency, or perhaps there were at a ploace like where here where only the cardiac fellows place chest tubes....Only surgical residents or cardiology fellows were allowed to float a PA catheter, so in the middle of the might, i would have to go to the MICU as an INtern, while the medicine chief watched me because the card fellow was at home.
My surgical ICU months/cardiac months as an anes resident were very easy...except for the LVAD patients......
In the ORI, I often felt more competent than the younger anesthesia attendings placing a cordis my first month of anesthesia residency, certainly better than most of the CA-3 residents I had done more of them.....I have no problem dropping a subclavian if I can't get the IJ, as well as all of the trauma experience....

This is my experience only, but if you go to a good community program, you will have lots of PA's, efficiency is a must, these place are in the profit business....I only did discharge summaries on weekends. Yes, even whe there were no hour limitations, it was fun.....If you are assertive, you will operate a lot..I still feel like I could kick the PGY-4's ass on a lap chole here....They just don;'t do enough because we have laparoscopic fellows.......

my two cents, but who the F*#& wants to spend half the day rounding....absolute torture. with the 80 hour work week, and going home post call, there is no way I would do a medicine internship.......Like I said, my internship was actually kind of fun.....even at 110+ some weeks.

I think you hit on two key points that helped make your experience and my experience as rich as they were: It's all about your confidence and aggressiveness in pursuing procedures and the confidence the staff has in you. I still have those ridiculous procedure books we were given to log in procedures. The number of procedures you got was definitely site specific but also resident driven. Not over 100 central lines as an intern (78 to be exact) but more than the surgery guys in my program. At some of the sites I rotated at predominantly, the MICU intern also covered the SICU. Granted this was a long time ago and may have changed, but you also helped out in the ER. The floor residents absorbed much of the useless scut.

If there was a surgery resident in house, they would usually be willing to let you do the procedures, especially since you were covering the medical issues and calls of their patients in the ICU. You take too long and they would take over, but otherwise they were available to back you up. I even got to cric several patients during codes where the surgery resident wasn't available for either a trach or as backup for intubation (3 out of 4 did have reasons for a cric - angioedema, obstructing mass, refractory asthma exacerbation - one unfortunately was an iatrogenic injury to the patient's epiglottis and right VC from multiple failed intubation attempts). Those put a few grays on my head and got one surgery resident fired for leaving the hospital on in house call.

The cardiology service of St. Paul University Hospital was/is a very resident friendly service and was where you got to place introducers and float PAC's. Clyde Yancy, Brian Baldwin, and Beth Bittner all gave me those opportunities on the cardiology patients when the fellows were busy or if there were no fellows available. Also got my first exposure to TEE, though couldn't really drive the train so to speak. Lot of exposure to ECG reading, TTE, and management of complex cardiac dysfunction.

The nephrology service of Southwestern places all of its own dialysis access catheters and will probably start it's own interventional service at some point next year.

The pulmonary service does it's own chest tube placements and again, if you had read up and were eager to do them, you got them. Quite frequently, as you said, the pulmonary attendings looked very uncomfortable placing them, so if you had the confidence and previous experience on your surgical sub I's or rotations to at least see how the surgeons did it, you could place them faster than the attendings. If you didn't know squat, thought an alcohol swab was sufficient infection prophylaxis, and forgot to anesthetize the incision site, you were quickly shooed away by the attendings. Not that I was too thrilled to put a chest tube in a patient with a known TB + effusion, but hey them's the risk.

Bottom line: Your effort level and efficiency will determine what you get to do. Myself and another person in my medicine class definitely broke the ceiling for number of procedures, but we were aggressive and prepared and yet the other residents in our class still got a fair number of procedures.

For either a medicine or surgery prelim, you need to do a thorough investigation to determine if you will actually be allowed to function as a working, thinking physician, or if you will be use as a filler to bridge the gap for work needs and to keep the categorical residents under the 80 hour work week. I have found the latter to be less common with medicine prelim years based on what I have seen and heard from the subsequent CA classes here and from what I have heard from my connections with other chief residents at other programs.

On the spectrum of prelim years, Jim, yours is definitely at or near the top, but likely more due to your personality, level of skill and intelligence, and aggressiveness. If you can say that every or most of the interns in your class had the same experience, then I would say that your internship site was/is a jewel (and that may or may not also reflect the number of interns in your class - less giving you more opportunities to do procedures).

For the medicine prelims as a whole, it would be difficult to have you function solely as a stopgap because you cannot order tests, write for meds, examine and diagnose patients, admit/discharge patients, etc. if you don't develop their ability to recognize and treat a wide variety of pathologies that you will see. In that sense, I feel that medicine provides you with a greater breadth and depth of understanding of pathology and physiology. Not to say that rheumatology will be of great use to you in the future, but solid foundations in nephrology, cardiology, pulmonology, ID, GI, and endocrinology are all applicable to anesthesiology and can definitely help you avoid disasters through a deeper preoperative understanding of individual patient's global concerns, as well as helping to guide your intraoperative and postoperative therapy. Procedures in a medicine prelim year will depend largely on the size of the service and your willingness to do the procedures ("Hey intern X, I want you put in a central line, but if you aren't comfortable or don't have time, consult general surgery or interventional radiology.")

You struck a home run with your internship, but you are less likely to strike out with a medicine year in my opinion.

 

[VentdependenT]

UT you are definitely hard core my man.

 

[UTSouthwestern]

UT you are definitely hard core my man.

Wish I was hardcore right now. Should be studying for the boards and all I've been able to do on this day off is surf the internet and watch movies. Star Wars III is really good by the way, if you turn off the dialogue.