Internal medicine procedures #s (CVLs, thoras, paras, intubations)

[Lexdiamondz]

Hey, EM resident here. I've got a good friend who is an MS3 strongly considering going into IM or EM, however he's rather turned off by the more unsavoury aspects of EM (the drunks, the homeless, the drug seekers, the occasionally violent/EDP). We both attend(ed) institutions with EM residencies so the ED tended to do many procedures, however were just curious on average, how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

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[sluggs]

Totally depends on the program and interest of the resident. Some programs are very ICU light with minimal procedural exposure. At a high volume academic center, you can get enough lines to get good. Intubation, in my opinion should be studied with an anesthesia month, even if you get a lot of icu tubes. Thoras should be plentiful and cx tubes less so unless you really hustle

 

[CCM-MD]

Hey, EM resident here. I've got a good friend who is an MS3 strongly considering going into IM or EM, however he's rather turned off by the more unsavoury aspects of EM (the drunks, the homeless, the drug seekers, the occasionally violent/EDP). We both attend(ed) institutions with EM residencies so the ED tended to do many procedures, however were just curious on average, how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

Variable from program to program and heavily dependent on the interest of the resident. IM attracts so many different personalities. The PC/rheum/endo/onc types don't want anything to do with procedures - and can probably get away with not doing any. The cards/pulm/ccm types want to do everything - and probably would be able to if they hustle. An interested resident at most programs should get enough exposure to paras > CVCs > art lines > LPs >thoras (in descending order).

Probably 0 to minimal exposure to airway management and chest tubes at most programs.

 

[lulu09]

Yes -- it totally varies by institution.

I would say across the country at minimum paras and CVCs are pretty typical procedures expected of IM residents. However CVCs are still quite variable across institutions -- we had heavy CCM support in my residency, so we weren't even expected to put in lines during codes or rapid responses (the CCM fellow did it). We were para and LP heavy though, so I graduated having done like 50-60 paras, 20-30 LPs, ~10 CVCs (in the ICU, all supervised). Tons (100+) of US-guided IVs (since we didn't have an IV team and RNs came to us directly if they couldn't get an IV in). I could have asked to do a couple of A-lines I guess too but I had no interest. Residents never did thoras or chest tubes unless they were gung-ho about pulm or CCM. I didn't think we (IM residents) were allowed to intubate period.

 

[Anicetus]

I’m at a university program for IM. It’s insanely easy to get certified in procedures. You kind of have to try to avoid it if you don’t want procedures. For example if your patient needs a central line, you can actively avoid it by just running away to work on notes or stating you aren’t “comfortable” putting one in. Otherwise If you take part in all of your patients care you can perform all of the procedures on them with supervision at first. It may not be the same at community or academic branch hospitals.

 

[CCM-MD]

University vs community hospital probably has little to do with it. One might argue that the lack of subspecialty fellows could lead to more procedure opportunities.

 

[Lexdiamondz]

I’m at a university program for IM. It’s insanely easy to get certified in procedures. You kind of have to try to avoid it if you don’t want procedures. For example if your patient needs a central line, you can actively avoid it by just running away to work on notes or stating you aren’t “comfortable” putting one in. Otherwise If you take part in all of your patients care you can perform all of the procedures on them with supervision at first. It may not be the same at community or academic branch hospitals.

How many do you guys need to be certified?

 

[gutonc]

How many do you guys need to be certified?

How many whats? CVLs? None. That's not an IM RRC core competency anymore. How many you need to be privileged for it at a subsequent job/hospital will depend.

 

[swimchick]

How many do you guys need to be certified?

Agree with what gutonc said - you don't need a certain number to be certified. That being said, the hospital I'm currently credentialed at required 10 paracentesis and 10 CVCs to receive privileges to perform those procedures.

 

[Redpancreas]

Hey, EM resident here. I've got a good friend who is an MS3 strongly considering going into IM or EM, however he's rather turned off by the more unsavoury aspects of EM (the drunks, the homeless, the drug seekers, the occasionally violent/EDP). We both attend(ed) institutions with EM residencies so the ED tended to do many procedures, however were just curious on average, how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

If you just want to get by, you could probably get away with doing one supervised paracentesis and no actual chest tubes/thoras in an IM residency. Last year, I really thought procedural exposure was important but now in residency, there’s a lot of skills that are more important to hone (juggling 10 patients, triaging, attention to detail, spotting emergencies, interpreting imaging/EKGs) that are far more valuable skills to develop than to learn a procedure that a million techs or nurses know how to do. I’d rather be the one person in the room who can definitively diagnose a rhythm on EKG or interpret an X-ray without a read than 1/10 people who can get airway/IV access during an emergency. It makes sense for ED or CC physicians to know procedures as they’re exposed directly to patients who crump fast. Otherwise, if you yearn to make differences with your hands, pursue a surgical career or become an IM proceduralist.

 

[Lexdiamondz]

If you just want to get by, you could probably get away with doing one supervised paracentesis and no actual chest tubes/thoras in an IM residency. Last year, I really thought procedural exposure was important but now in residency, there’s a lot of skills that are more important to hone (juggling 10 patients, triaging, attention to detail, spotting emergencies, interpreting imaging/EKGs) that are far more valuable skills to develop than to learn a procedure that a million techs or nurses know how to do. I’d rather be the one person in the room who can definitively diagnose a rhythm on EKG or interpret an X-ray without a read than 1/10 people who can get airway/IV access during an emergency. It makes sense for ED or CC physicians to know procedures as they’re exposed directly to patients who crump fast. Otherwise, if you yearn to make differences with your hands, pursue a surgical career or become an IM proceduralist.

And I think that mentality is what differentiates EM vs IM. For us, being able to intervene is almost as important as being able to interpret and synthesise information, and often we're working on next to no information to begin with. My question was more wanting to gauge what opportunities there would be in an IM training pathway for someone more procedurally minded. Thanks for your input.

 

[Redpancreas]

And I think that mentality is what differentiates EM vs IM. For us, being able to intervene is almost as important as being able to interpret and synthesise information, and often we're working on next to no information to begin with. My question was more wanting to gauge what opportunities there would be in an IM training pathway for someone more procedurally minded. Thanks for your input.

I think that mentality is actually what differentiates physicians from techs/nurses frankly. If you want to, you can learn any procedure (ultrasound guided lines, thoracentesis, paracentesis, intubation, etc.). Nurses are learning these procedures, so can any medical doctor with the right guidance and ICU and ED rotations are typically where Internists learn these skills. A CCM fellowship allow for entire months dedicated to learning these procedures.

 

[CCM-MD]

I think that mentality is actually what differentiates physicians from techs/nurses frankly. If you want to, you can learn any procedure (ultrasound guided lines, thoracentesis, paracentesis, intubation, etc.). Nurses are learning these procedures, so can any medical doctor with the right guidance and ICU and ED rotations are typically where Internists learn these skills. A CCM fellowship allow for entire months dedicated to learning these procedures.

I agree with most of what you said. But as important/cool as procedures may seem - they are a tiny part of CCM. Like you said, you can train a midlevel to do lines. The diagnosis and management part of things is much more important and much harder to learn.

 

[Raryn]

Hey, EM resident here. I've got a good friend who is an MS3 strongly considering going into IM or EM, however he's rather turned off by the more unsavoury aspects of EM (the drunks, the homeless, the drug seekers, the occasionally violent/EDP). We both attend(ed) institutions with EM residencies so the ED tended to do many procedures, however were just curious on average, how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

The IM RRC only has three required procedures last I checked - arterial sticks, venous sticks, and pap smears. There's no "minimum" on those anymore, but the program has to certify you're able to do them, so a soft minimum is 5. Most programs just count art/central lines towards art/venous sticks respectively.

That said, lines/paras/thoras/LPs/tubes are required to be understood by every IM graduate, and the majority of programs have some requirement for them to actually be performed. My program was more procedure heavy than most - we were required to have 10 CVCs, 5 thoras/paras/LPs/art lines, some joint injections (3?), etc to graduate. Tubes were optional. Many of us had a lot more - I personally had well over 50 central lines (stopped logging them the last few months) including a dozen or more subclavian lines (IJ/fem started getting boring so I had the fellows show me how to do them), a dozen or so tubes, etc.

Since I've graduated, I've done two total lines while moonlighting as a hospitalist. Zero procedures otherwise.

 

[IMreshopeful]

I think it’s important to have a core set of procedural skills as an IM resident irrespective of what specialty you are going into. I don’t care if you are doing endo or ID - if you are a resident working in my CCU, you need to be able to at least attempt a line. I don’t mind coaching you through one - but you’d better take care of your patient and know what you’re doing. My residency was very critical care heavy and we didn’t always have fellow or attending backup at night - I became very comfortable doing central lines and arterial lines in both stable and crash situations. I graduated doing 30-40 CVCs (including subclavian), 30+ arterial lines, more paras than I care to count, and lots of thoras and LPs.

I agree that in medicine your ability to synthesize history and physical info, form a differential, interpret an EKG, CXR, and labs, is what separates us from EM, who by and large focuses on triaging sick and not sick, diagnosing what will kill you, and consulting the appropriate service when necessary. Both are absolutely essential services and you could argue that being more procedurally versatile is more core to EM training. After all IM unless you do certain subspecialties you won’t do fracture reductions, emergency thoracotomies and internal cardiac massage, etc.

But that being said - and I think I’m a bit of a dinosaur in this - even if you never intend to do procedures ever, it should be a core competency and capability for an IM resident. I think being able to slam in a line acutely is as important a skill as synthesizing all the data because it really makes you appreciate the situation in a well rounded manner. It also shows confidence in being able to manage the patient.

As a third year cards fellow I do think my line competency helped me a great deal. I can do much more advanced procedures with ease (cardiac catheterization, TEE, TVPs) and can usually put a crash line in within eight minutes from opening the kit to suture. But determining who needs the TVP, who needs the balloon pump or Impella, who gets a swan, who will benefit from the procedure and how to manage and interpret the device are all part and parcel in IM - not just procedurize and stabilize, which is often what you see in EM

 

[jdh71]

Eh

 

[ItsSurgicallyComplicated]

You are doing a disservice to your patients if you dont become competent and comfortable with intubation and central line placement.

 

[CCM-MD]

You are doing a disservice to your patients if you dont become competent and comfortable with intubation and central line placement.

Yeah. That is not true.

 

[rokshana]

You are doing a disservice to your patients if you dont become competent and comfortable with intubation and central line placement.

as IM? for intubation? why? as a resident, most programs don't have that as something that they do...that is why you have anesthesia residents...it is far more important that they learn how to do that.

 

[Raryn]

You are doing a disservice to your patients if you dont become competent and comfortable with intubation and central line placement.

I'm not comfortable with intubation today - it's been 2 years since I've done one, and even then I hadn't done all that many relative to my colleagues in anesthesia, EM, or P/CC. I'm still fully capable of picking up a hospitalist shift - every hospital that I've ever worked at has anesthesia in some stripe available within 30 minutes (even if it's just a CRNA). I can think of very few internists outside of a rural environment that would ever be intubating on their own.

 

[IMreshopeful]

You are doing a disservice to your patients if you dont become competent and comfortable with intubation and central line placement.

Disagree about intubation but I definitely agree central line placement should be a core competency

 

[CCM-MD]

Outpatient IM, allergy, endo, rheum, GI, nephro, ID, pulm alone, heme, onc, geriatrics, palliative... none of these specialties/practice settings require you to be competent in airway management or lines. Don’t need to do lines/tubes for most Hospitalist gigs either - rural shops being the exception.

Above is like >80% of IM. So sure, for the remaining (cards or ccm and maybe rural hospitalist) lines in residency would be helpful.

 

[jdh71]

I think it's good to be introduced to procedures during initial residency training but find it naive to think that all or most should come out of residency "competent" in things like lines and intimations when those numbers are going to be very low relatively speaking for the vast majority of residents.

 

[ItsSurgicallyComplicated]

as IM? for intubation? why? as a resident, most programs don't have that as something that they do...that is why you have anesthesia residents...it is far more important that they learn how to do that.

Not everyone works in a big university hospital. I am not saying you should master it in residency, but if as an attending you are working inpatient, I think you should know how to put a tube or line with minimum competence.

 

[rokshana]

Not everyone works in a big university hospital. I am not saying you should master it in residency, but if as an attending you are working inpatient, I think you should know how to put a tube or line with minimum competence.

have you ever worked as a hospitalist?? It wold be a rare bird that does intubations, even at a the community hospitals...one, most IM trained doctors don't have enough experience to do intubations and two, hospitalist don't have time for that...in many community hospitals, they don't run the codes in the hospital and if they are managing the icu, they rely on anesthesia or RT to intubate.

you say you are a plastics fellow, but i doubt that you have had little in the way of contact with IM or Hospitalists if you think that intubations are routinely done by them.

Central Lines are done by a lot of residents, but out in the real world of Hospital medicine, they are rarely used outside of the ICU and then are done by the intensivist....on the floors and even the ICU, PICC lines are utilized more and they are placed by PICC nurses...the general hospitalist, again, will have little time to spend doing lines.

 

[PlutoBoy]

I think hospitalists should be able to obtain IV access, perform LPs, thoracentesis, and paracentesis. This is not the current state of affairs but I think that this is what should happen.

 

[rokshana]

I think hospitalists should be able to obtain IV access, perform LPs, thoracentesis, and paracentesis. This is not the current state of affairs but I think that this is what should happen.

why? they are not procedures that the vast majority of Hospitalists will do or have time to do (maybe in some rural place where there is no IR or surgeon available).

 

[Siggy]

why? they are not procedures that the vast majority of Hospitalists will do or have time to do (maybe in some rural place where there is no IR or surgeon available).

...because there's nothing stupider than admitting someone on Friday night for a routine paracentesis when IR opens back up on Monday. Besides, at least in terms of thoras and paras, they aren't complicated or technically challenging procedures.

 

[PlutoBoy]

why? they are not procedures that the vast majority of Hospitalists will do or have time to do (maybe in some rural place where there is no IR or surgeon available).

The vast majority does not perform these procedures but they should in my opinion. A hospital medicine specialist should be able to establish IV access, which is something that over 90% of admitted patients will need. I think that this is not an unreasonable expectation.

Paracentesis and thoracentesis are procedures that are also needed frequently. The ideal hospitalist should perform these procedures.

Whether hospitalists have time to do the procedure or not is irrelevant. This is a problem with administration overworking their hospitalists and should have no bearing on procedural competence.

At the bare minimum a hospitalist should be able to establish IV access and perform a paracentesis. I could give you a break on thoracentesis.

 

[rokshana]

The vast majority does not perform these procedures but they should in my opinion. A hospital medicine specialist should be able to establish IV access, which is something that over 90% of admitted patients will need. I think that this is not an unreasonable expectation.

Paracentesis and thoracentesis are procedures that are also needed frequently. The ideal hospitalist should perform these procedures.

Whether hospitalists have time to do the procedure or not is irrelevant. This is a problem with administration overworking their hospitalists and should have no bearing on procedural competence.

At the bare minimum a hospitalist should be able to establish IV access and perform a paracentesis. I could give you a break on thoracentesis.

Do you mean a peripheral IV? I have yet to see a pt come out of the ED without a PIV...which has been placed by a nurse. And if they somehow dont get an IV in the ED then the floor nurse will place that. Other than in NYC, I don’t think I have ever seen that as something that IM residents or hospitalists do.Central line? Not done on floor pts and if in the icu, then the intensivist is doing the line.
LOL that you do think not having the time to do a procedure isn’t relevant? I get consults for diabetes management from Hospitalists....which any mid year resident should be able to manage much less a board certified IM physician ...but it’s about the census they have and what they can delegate out...sad but true...

 

[PlutoBoy]

Do you mean a peripheral IV? I have yet to see a pt come out of the ED without a PIV...which has been placed by a nurse. And if they somehow dont get an IV in the ED then the floor nurse will place that. Other than in NYC, I don’t think I have ever seen that as something that IM residents or hospitalists do.Central line? Not done on floor pts and if in the icu, then the intensivist is doing the line.
LOL that you do think not having the time to do a procedure isn’t relevant? I get consults for diabetes management from Hospitalists....which any mid year resident should be able to manage much less a board certified IM physician ...but it’s about the census they have and what they can delegate out...sad but true...

IV access in general. Patients lose IV access all the time. A hospitalist should be able to obtain IV access.

Obtain peripheral access with US guidance, put in an EJ, place a central line. Whatever the method, establishing IV access is critical in the hospital and I don’t think this is too much to ask from a hospital specialist.

Drawing blood is also a reasonable expectation. I’ve had to use an ultrasound to draw blood before. I’ve needed to draw blood from the neck also. If you stick around the wards for long enough it will happen.

Oh and I’ve placed central lines in the general medical wards too. If everytime I need a blood draw no one can find a vein, or if the patient keeps losing peripheral IV access, a central line comes in handy.

 

[CCM-MD]

IV access in general. Patients lose IV access all the time. A hospitalist should be able to obtain IV access.

Obtain peripheral access with US guidance, put in an EJ, place a central line. Whatever the method, establishing IV access is critical in the hospital and I don’t think this is too much to ask from a hospital specialist.

Drawing blood is also a reasonable expectation. I’ve had to use an ultrasound to draw blood before. I’ve needed to draw blood from the neck also. If you stick around the wards for long enough it will happen.

Oh and I’ve placed central lines in the general medical wards too. If everytime I need a blood draw no one can find a vein, or if the patient keeps losing peripheral IV access, a central line comes in handy.

Nurse run Midline/PICC teams is what you need.

If you're working somewhere that has attendings drawing blood under ultrasound probably should find a better job...

 

[PlutoBoy]

Nurse run Midline/PICC teams is what you need.

If you're working somewhere that has attendings drawing blood under ultrasound probably should find a better job...

I was not going to insert a PICC line in a patient that I was about to discharge just so my nurse could do a blood draw. I walked in the room with an US probe and a syringe, located a blood vessel, drew some blood, handed it to the nurse, and walked out. Took me a minute.

Establishing IV access is the bare minimum expectation from a physician that claims to be an inpatient medicine specialist. It is also fairly easy to do if you get decent with the ultrasound.

 

[SpacemanSpifff]

Hey, EM resident here. I've got a good friend who is an MS3 strongly considering going into IM or EM, however he's rather turned off by the more unsavoury aspects of EM (the drunks, the homeless, the drug seekers, the occasionally violent/EDP). We both attend(ed) institutions with EM residencies so the ED tended to do many procedures, however were just curious on average, how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

The IM residents at my institution (university referral center) seem to be fairly facile with central lines and arterial lines, because they spend a decent amount of time in the MICU and cardiac ICU where they have patients that require vasoactives and invasive monitoring. My buddies who are at community programs seem to be even more comfortable with lines, maybe because of the lack of fellows. Chest tubes - no IM residents at my shop, or any of my IM friends elswhere, are putting in chest tubes. Airways, seems to depend on if the person is interested in gaining experience with them or not.

If you just want to get by, you could probably get away with doing one supervised paracentesis and no actual chest tubes/thoras in an IM residency. Last year, I really thought procedural exposure was important but now in residency, there’s a lot of skills that are more important to hone (juggling 10 patients, triaging, attention to detail, spotting emergencies, interpreting imaging/EKGs) that are far more valuable skills to develop than to learn a procedure that a million techs or nurses know how to do. I’d rather be the one person in the room who can definitively diagnose a rhythm on EKG or interpret an X-ray without a read than 1/10 people who can get airway/IV access during an emergency. It makes sense for ED or CC physicians to know procedures as they’re exposed directly to patients who crump fast. Otherwise, if you yearn to make differences with your hands, pursue a surgical career or become an IM proceduralist.

I'd rather be able to do both.

 

[TheNextLevel]

Number of procedures as a resident is the wrong place to focus.

Internal medicine is a very heterogeneous specialty with people experiencing very different training even within the same institution. As a cardiology fellow, I've obtained venous and arterial access hundreds of times over the course of my training. and left residency with >30 central lines. Peers who trained in the same institution who were less procedurally inclined as residents , and are now rheumatology or endocrinology fellows - they identified early on that they would have no need to know how to do a central line and will never be responsible for a critically ill patient. These folks will finish their training with single-digit numbers of these procedures.

After now having seen things from a fellow perspective in the CCU, some internal medicine residents are interested in performing procedures and others clearly are not.

Folks who are not interested/motivated in doing procedures won't do as many at my institution, because myself or another cardiology fellow in the unit will be more than happy to line up an unstable patient if you'd rather sit at the computer finishing your notes.
.
Things become more uniform at the fellowship level, but you still have pretty much infinite career options. If your friend wants to do critical care, there is obviously an entire IM fellowship dedicated to obtaining mastery in critical care. There are IM pathway fellowships where you perform high-level procedures (catheter ablation in the electrophysiology lab, TAVR or CTO cases in the cath lab, ERCP), and those where you do none (endocrine). If he changes his mind and wants to become an imager, he can do cardiology and specialize in cardiac MRI, nuclear imaging and echocardiography.

If you are comparing hospitalist to EM (equivalent training duration), and procedures are a priority, then choose EM. But keep in mind that there are IM specialties where you do way more procedures than an EM.

 

[Merely]

I think it’s important to have a core set of procedural skills as an IM resident irrespective of what specialty you are going into. I don’t care if you are doing endo or ID - if you are a resident working in my CCU, you need to be able to at least attempt a line. I don’t mind coaching you through one - but you’d better take care of your patient and know what you’re doing. My residency was very critical care heavy and we didn’t always have fellow or attending backup at night - I became very comfortable doing central lines and arterial lines in both stable and crash situations. I graduated doing 30-40 CVCs (including subclavian), 30+ arterial lines, more paras than I care to count, and lots of thoras and LPs.

I agree that in medicine your ability to synthesize history and physical info, form a differential, interpret an EKG, CXR, and labs, is what separates us from EM, who by and large focuses on triaging sick and not sick, diagnosing what will kill you, and consulting the appropriate service when necessary. Both are absolutely essential services and you could argue that being more procedurally versatile is more core to EM training. After all IM unless you do certain subspecialties you won’t do fracture reductions, emergency thoracotomies and internal cardiac massage, etc.

But that being said - and I think I’m a bit of a dinosaur in this - even if you never intend to do procedures ever, it should be a core competency and capability for an IM resident. I think being able to slam in a line acutely is as important a skill as synthesizing all the data because it really makes you appreciate the situation in a well rounded manner. It also shows confidence in being able to manage the patient.

As a third year cards fellow I do think my line competency helped me a great deal. I can do much more advanced procedures with ease (cardiac catheterization, TEE, TVPs) and can usually put a crash line in within eight minutes from opening the kit to suture. But determining who needs the TVP, who needs the balloon pump or Impella, who gets a swan, who will benefit from the procedure and how to manage and interpret the device are all part and parcel in IM - not just procedurize and stabilize, which is often what you see in EM

I hate this mentality...bro we get it you’re cardiology and like to do procedures good for you. Why the hell are you gonna try and make a guy wanting to do strictly outpatient (endo,Rheum,pcp) put in lines? They don’t want to put in lines yet you’re still gonna force them to attempt it on the patient? That’s not in the patients best interest since they aren’t trying to learn and the patient would benefit from someone more skilled putting it in...very annoying

 

[Death and Taxes]

...how many critical care procedures to IM residents typically get to perform doing residency, particularly CVLs, Intubations (and airway management in general) and chest tubes/thoras.

IM with no cc fellows and icu heavy curriculum

CVLs: 10-15 per year or more depending on how much ICU and night flight you have scheduled
Art lines: Same as centrals, some do many more.
Intubations: 20-50 during mandatory anesthesia rotation, rarely after unless you want to.
0 chest tubes
0 paracentesis
0 LPs
Rarely IVs, I'm practicing US guided IVs on my own so I dont need to get midlines and PICCs as often

Sent from my SM-G955U using Tapatalk

 

[lulu09]

IM with no cc fellows and icu heavy curriculum

CVLs: 10-15 per year or more depending on how much ICU and night flight you have scheduled
Art lines: Same as centrals, some do many more.
Intubations: 20-50 during mandatory anesthesia rotation, rarely after unless you want to.
0 chest tubes
0 paracentesis
0 LPs
Rarely IVs, I'm practicing US guided IVs on my own so I dont need to get midlines and PICCs as often

Sent from my SM-G955U using Tapatalk

That's really interesting. My program was basically the reverse -- we graduate being literally masters of paras and very comfortable with LPs. In a program with no CCM if the residents didn't do paras who did them? IR? We literally have to grovel to IR (or US) to get them to do the difficult taps in our institution...NIR was marginally nicer to us for hard LPs.

 

[Death and Taxes]

That's really interesting. My program was basically the reverse -- we graduate being literally masters of paras and very comfortable with LPs. In a program with no CCM if the residents didn't do paras who did them? IR? We literally have to grovel to IR (or US) to get them to do the difficult taps in our institution...NIR was marginally nicer to us for hard LPs.

ED must filter out many paras and IR gets the rest

Sent from my SM-G955U using Tapatalk

 

[PlutoBoy]

ED must filter out many paras and IR gets the rest

Sent from my SM-G955U using Tapatalk

Hmmm... I would assume that they would punt to the admitting team because a paracentesis is almost never an emergency.

 

[IMreshopeful]

I hate this mentality...bro we get it you’re cardiology and like to do procedures good for you. Why the hell are you gonna try and make a guy wanting to do strictly outpatient (endo,Rheum,pcp) put in lines? They don’t want to put in lines yet you’re still gonna force them to attempt it on the patient? That’s not in the patients best interest since they aren’t trying to learn and the patient would benefit from someone more skilled putting it in...very annoying

Because our academic residency gives a lot of autonomy to the residents and there are services at night where they cover critically ill patients or those with the potential to decompensate. Without attending or fellow in house backup besides from home. I had to do it as a resident too, as did my colleagues who were going into rheum and endo and primary care. This has nothing to do with my personal career “bro” but nice deflection.

And pray tell how do you develop confidence with taking care of sick patients and skill without actually doing it? By that logic we shouldn’t have residents taking care of patients period. There are numerous residencies - highly ranked ones at that - where interns are expected to be able to work up and make plans on their patients from within a few months of starting. It’s a high expectation but it reflects the caliber of what we want in an IM training that’ll result in good doctors.

Sorry, but if you’re an IM resident, I think you should be competent enough to handle whatever rotation you’re on. I didn’t like cancer rotations but I sure as hell still had to do them and I made sure to learn and be as competent on them as possible. I wouldn’t call the ID doc to evaluate someone to be put on amphotericin or some other bazooka antibiotic in the middle of the night... I would trust my training and judgement and try to institute therapy early in order to stabilize the patient. This may be a difference of opinion where we may simply not agree.

 

[PlutoBoy]

Because our academic residency gives a lot of autonomy to the residents and there are services at night where they cover critically ill patients or those with the potential to decompensate. Without attending or fellow in house backup besides from home. I had to do it as a resident too, as did my colleagues who were going into rheum and endo and primary care. This has nothing to do with my personal career “bro” but nice deflection.

And pray tell how do you develop confidence with taking care of sick patients and skill without actually doing it? By that logic we shouldn’t have residents taking care of patients period. There are numerous residencies - highly ranked ones at that - where interns are expected to be able to work up and make plans on their patients from within a few months of starting. It’s a high expectation but it reflects the caliber of what we want in an IM training that’ll result in good doctors.

Sorry, but if you’re an IM resident, I think you should be competent enough to handle whatever rotation you’re on. I didn’t like cancer rotations but I sure as hell still had to do them and I made sure to learn and be as competent on them as possible. I wouldn’t call the ID doc to evaluate someone to be put on amphotericin or some other bazooka antibiotic in the middle of the night... I would trust my training and judgement and try to institute therapy early in order to stabilize the patient. This may be a difference of opinion where we may simply not agree.

To be honest, I don’t disagree with ABIM procedural requirements. My point is that you should be able to do the basic procedures of your specialty. In other words, a hospitalist should be able to obtain IV access at least, an intesivist and an EM doc should be able to intubate, a rheumatologist should be able to tap a knee, etc...

 

[Merely]

Because our academic residency gives a lot of autonomy to the residents and there are services at night where they cover critically ill patients or those with the potential to decompensate. Without attending or fellow in house backup besides from home. I had to do it as a resident too, as did my colleagues who were going into rheum and endo and primary care. This has nothing to do with my personal career “bro” but nice deflection.

And pray tell how do you develop confidence with taking care of sick patients and skill without actually doing it? By that logic we shouldn’t have residents taking care of patients period. There are numerous residencies - highly ranked ones at that - where interns are expected to be able to work up and make plans on their patients from within a few months of starting. It’s a high expectation but it reflects the caliber of what we want in an IM training that’ll result in good doctors.

Sorry, but if you’re an IM resident, I think you should be competent enough to handle whatever rotation you’re on. I didn’t like cancer rotations but I sure as hell still had to do them and I made sure to learn and be as competent on them as possible. I wouldn’t call the ID doc to evaluate someone to be put on amphotericin or some other bazooka antibiotic in the middle of the night... I would trust my training and judgement and try to institute therapy early in order to stabilize the patient. This may be a difference of opinion where we may simply not agree.

You’re at a place where IM residents are managing critical care patients with no in house backup? Wow I do not want to be a patient where you are..managing patients is an important skill you should learn regardless of the rotation..I’m talking about procedures. It is doing a disservice to your patients by having an inexperienced person doing their procedure when that resident will not need that experience moving forward. Let’s say a complication happens while once of your IM residents that’s going into endo is doing a procedure, what have we gained from this situation? A patient that is now worse off and a resident that is more experienced in something he doesn’t need to be experienced in...that’s so great. Put the patient first and think about it like it’s your family, would you want an uninterested resident doing your moms procedure or a thoughtful attending?

 

[IM88]

You’re at a place where IM residents are managing critical care patients with no in house backup? Wow I do not want to be a patient where you are..managing patients is an important skill you should learn regardless of the rotation..I’m talking about procedures. It is doing a disservice to your patients by having an inexperienced person doing their procedure when that resident will not need that experience moving forward. Let’s say a complication happens while once of your IM residents that’s going into endo is doing a procedure, what have we gained from this situation? A patient that is now worse off and a resident that is more experienced in something he doesn’t need to be experienced in...that’s so great. Put the patient first and think about it like it’s your family, would you want an uninterested resident doing your moms procedure or a thoughtful attending?

I wouldn't over-value the idea of attending supervision:
1) This trial (NEJM) randomized in-house nocturnal intensivists to an otherwise resident-run, high-acuity, academic MICU. They found no difference in either the primary outcome of time to ICU discharge, or any of the secondary outcomes including ICU mortality, hospital mortality, discharge home from hospital, or ICU readmission.
2) This trial (Effect of Increased Supervision on Medical Errors, Patient Safety, and Resident Education) randomized general medicine services at a large academic medical center to effectively more vs. less attending supervision. They similarly found no difference in patient outcomes, and residents felt more autonomous in the less supervision group.

 

[throwaway1939]

You’re at a place where IM residents are managing critical care patients with no in house backup? Wow I do not want to be a patient where you are..managing patients is an important skill you should learn regardless of the rotation..I’m talking about procedures. It is doing a disservice to your patients by having an inexperienced person doing their procedure when that resident will not need that experience moving forward. Let’s say a complication happens while once of your IM residents that’s going into endo is doing a procedure, what have we gained from this situation? A patient that is now worse off and a resident that is more experienced in something he doesn’t need to be experienced in...that’s so great. Put the patient first and think about it like it’s your family, would you want an uninterested resident doing your moms procedure or a thoughtful attending?

most academic IM programs have upper levels run the ICU. At my program, two 3rd years are the only doctors in the MICU overnight. A single 3rd year and intern handles the entire CICU. There is anesthesia back-up for airways, but the expectation is that you would handle anything that walks through the door. The attending/fellow is nominally a phone call away, but the expectation is they are only called in for emergencies (eg someone needing a chest tube).

 

[CCM-MD]

I wouldn't over-value the idea of attending supervision

That is a dangerous statement.

Below is right out of the study you quoted. "Residents were expected to review all new admissions and critical events with a fellow, an intensivist, or both, in person or by telephone within 1 hour." Sure, the attendings weren't PHYSICALLY present in the hospital but the residents were still supervised.

There are numerous situations where I felt I was doing stuff independently as a resident but as an attending I have realized how many of the important decisions were directed by my attendings at the time.

 

[IM88]

Sure, the attendings weren't PHYSICALLY present in the hospital but the residents were still supervised.

I think this is an important distinction, though. The act of being on the "front lines" and having to make critical decisions or perform urgent procedures in difficult situations is a huge growth opportunity. Calling a supervising physician (fellow/attending) within an hour of a significant event or admission is very different than having an attending/fellow in-house where you run the risk that they may completely take over any independent decision making. For critically-ill patients, a lot can happen in the span of an hour. Ideally there's some balance, and I think there are definitely advantages and disadvantages of both models.

That is a dangerous statement.

I don't mean to suggest that supervision isn't useful - I just wanted to highlight that the evidence doesn't necessarily support the sentiment that patient care suffers by not having immediate attending oversight.

 

[IMreshopeful]

You’re at a place where IM residents are managing critical care patients with no in house backup? Wow I do not want to be a patient where you are..managing patients is an important skill you should learn regardless of the rotation..I’m talking about procedures. It is doing a disservice to your patients by having an inexperienced person doing their procedure when that resident will not need that experience moving forward. Let’s say a complication happens while once of your IM residents that’s going into endo is doing a procedure, what have we gained from this situation? A patient that is now worse off and a resident that is more experienced in something he doesn’t need to be experienced in...that’s so great. Put the patient first and think about it like it’s your family, would you want an uninterested resident doing your moms procedure or a thoughtful attending?

It is as posters above me have commented very common for no attending to be in house or fellow to be in house at night at an academic center. They are always available by phone to staff new admissions or if you are truly having a bear of a time with managing someone - and the fellow comes in if things are really hitting the fan - but what I am describing is not out of the ordinary.

If you are not capable of at least doing a central line on your own by the time you are a third year there are usually other residents or fellows elsewhere in the hospital... surgery is available as backup... but frankly I don’t want my residents to be dependent on surgeons to put their lines in for them!

Like I said we are not going to agree on this. There is a value in not having a fellow or attending do everything for you.

 

[Merely]

It is as posters above me have commented very common for no attending to be in house or fellow to be in house at night at an academic center. They are always available by phone to staff new admissions or if you are truly having a bear of a time with managing someone - and the fellow comes in if things are really hitting the fan - but what I am describing is not out of the ordinary.

If you are not capable of at least doing a central line on your own by the time you are a third year there are usually other residents or fellows elsewhere in the hospital... surgery is available as backup... but frankly I don’t want my residents to be dependent on surgeons to put their lines in for them!

Like I said we are not going to agree on this. There is a value in not having a fellow or attending do everything for you.

So just so we’re clear, you’re okay with an uninterested resident doing procedures on your family members right? I know I’m not so I wouldn’t have residents do procedures on my patients but if you are more power to you.

 

[PlutoBoy]

When I covered the MICU and called the attending in the middle of the night, he would ask me “Do you actually have a question for me?” before I even presented the case.

Usually, my answer was no and he would say “Good. We’ll talk about it in the morning” and hang up. Fun times.