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

[rokshana]

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.

If they are an IM resident, they they need to be interested in what is part of their training...while they may want to become an endocrinologist or rheumatologist, they are not one, they are training for IM (and I am an endocrinologist and planned on being one from the get) and need to master the things that are important to master as a resident. This will be slightly different depending on the program.

Personally, I wasn’t a big fan of cardiology or hem/Onc but it didn’t keep me from doing the things I needed to do as a resident when I was on those services...by your rationale, if a resident is uninterested in doing cardiology, they they shouldn’t be forced to do a cards rotation.

Where I trained,we required to have a certain number of procedures under our belt but once achieved didn’t necessarily have to do more... it gave us the ability to know how to do them regardless of what our future goals.

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[TheNextLevel]

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).

If a third year resident is expected to "handle anything that walks in the door" in your CICU, then that says something about the complexity of care being delivered at your center.

In a large transplant/VAD center there needs to be somebody who can float an emergent TVP, place a PA catheter and use the hemodynamics to adjust inotropes/nipride or guide escalation to mechanical circulatory support, recognize and treat acute rejection, manage VT storm, reprogram ICD/pacemakers using device programmers, perform TEE to evaluate for ruptured pap muscle or dissection, etc.

A third year resident can't and shouldn't be trusted to do things like that, or even recognize when they are necessary. Quite simply, you don't know what you don't know at that stage of your training when it comes to managing advanced heart failure/cardiogenic shock or complicated ACS. As a first year fellow, I was still calling in upper level support for this stuff and can remember a few misses.

 

[deleted547339]

If they are an IM resident, they they need to be interested in what is part of their training...while they may want to become an endocrinologist or rheumatologist, they are not one, they are training for IM (and I am an endocrinologist and planned on being one from the get) and need to master the things that are important to master as a resident. This will be slightly different depending on the program.

Personally, I wasn’t a big fan of cardiology or hem/Onc but it didn’t keep me from doing the things I needed to do as a resident when I was on those services...by your rationale, if a resident is uninterested in doing cardiology, they they shouldn’t be forced to do a cards rotation.

Where I trained,we required to have a certain number of procedures under our belt but once achieved didn’t necessarily have to do more... it gave us the ability to know how to do them regardless of what our future goals.

That argument doesn’t hold. There is a huge difference between learning the head knowledge of cardiology that will at least in same way, shape or form influence your practice in any medicine subspecialty and performing a procedure that you will literally never perfom again as a subspecialist.

And even to push a little harder, there are proponents for accelerated pathways like already exist in the combined residency/fellowship/research pathways.

 

[mercaptovizadeh]

If they are an IM resident, they they need to be interested in what is part of their training...while they may want to become an endocrinologist or rheumatologist, they are not one, they are training for IM (and I am an endocrinologist and planned on being one from the get) and need to master the things that are important to master as a resident. This will be slightly different depending on the program.

Personally, I wasn’t a big fan of cardiology or hem/Onc but it didn’t keep me from doing the things I needed to do as a resident when I was on those services...by your rationale, if a resident is uninterested in doing cardiology, they they shouldn’t be forced to do a cards rotation.

Where I trained,we required to have a certain number of procedures under our belt but once achieved didn’t necessarily have to do more... it gave us the ability to know how to do them regardless of what our future goals.

Well, yes and no. I've been signed off on thoras but would I feel comfortable doing one now, even ~1 year after being signed off? Heck no. Doing something 5 times and being "signed off" where the risks are substantial doesn't give me comfort, but I know many gung ho people who love doing procedures who felt comfortable doing them after the 1st one, perhaps because their enthusiasm for the procedure overrode any concern about potential mistakes and complications.

 

[rokshana]

That argument doesn’t hold. There is a huge difference between learning the head knowledge of cardiology that will at least in same way, shape or form influence your practice in any medicine subspecialty and performing a procedure that you will literally never perfom again as a subspecialist.

And even to push a little harder, there are proponents for accelerated pathways like already exist in the combined residency/fellowship/research pathways.

sure it does...there are plenty of programs where there is no dedicated cardiology service or hem/onc or nephro service and they learn the knowledge needed for these specialties just fine...no need to be on a CCU or a even dedicated cards service to learn all that is needed...so if I don't plan on doing cardiology why would i need to do a cards month or a CCU month? After all, once i'm a say, an endocrinologist, I'm not going to have to manage complex cardiology pt (though I do need to know how to recognize afib ).

While I may not ever do a paracentesis or a central line as an endocrinologist, I did need to know how to do them while i was a resident and i would have been a bit of hindrance to my seniors if i didn't know them and more importantly, would not have been a good senior if I couldn't teach my juniors how to do common procedures.

And sure there are accelerated programs, but they generally remove electives for the acceleration, not required rotations.

 

[rokshana]

Well, yes and no. I've been signed off on thoras but would I feel comfortable doing one now, even ~1 year after being signed off? Heck no. Doing something 5 times and being "signed off" where the risks are substantial doesn't give me comfort, but I know many gung ho people who love doing procedures who felt comfortable doing them after the 1st one, perhaps because their enthusiasm for the procedure overrode any concern about potential mistakes and complications.

i agree, i wasn't ever comfortable doing thoras my whole residency but A line became second nature (w/o an U/S to boot!), so just because you don't plan on doing procedures after residency doesn't necessarily mean that you shouldn't be exposed to them...you never know what you end up liking and even becoming proficient!(Couldn't do an A line to save my life now...).

 

[deleted547339]

sure it does...there are plenty of programs where there is no dedicated cardiology service or hem/onc or nephro service and they learn the knowledge needed for these specialties just fine...no need to be on a CCU or a even dedicated cards service to learn all that is needed...so if I don't plan on doing cardiology why would i need to do a cards month or a CCU month? After all, once i'm a say, an endocrinologist, I'm not going to have to manage complex cardiology pt (though I do need to know how to recognize afib ).

While I may not ever do a paracentesis or a central line as an endocrinologist, I did need to know how to do them while i was a resident and i would have been a bit of hindrance to my seniors if i didn't know them and more importantly, would not have been a good senior if I couldn't teach my juniors how to do common procedures.

And sure there are accelerated programs, but they generally remove electives for the acceleration, not required rotations.

You need to do the other rotations to understand how the disease processes you treat are influenced by other diseases and how they crossover. You need to know about heart failure because you treat thyroid diseases that can lead to heart failure and understand what that looks like. You need to know about coronary disease because you will have diabetics you manage and need to understand the diagnostics and therapeutics involved in managing coronary syndrome. The head knowledge of understanding medicine broadly serves everyone well. That’s why it can be infuriating when you talk to a surgical subspecialist who knows their disease process well but can’t see the patient as a whole.

That is an entirely different thing from being facile in a procedure that you never do. You need to have the head knowledge about what the procedure entails, indications, the potential complications, etc. - but there is absolutely no need for you to have the hands. If you take your argument to it’s logical conclusion, you shouldn’t go on to residency in internal medicine until you’ve mastered the surgical procedures you’re exposures to in med school. The fact of the matter is that there is value in knowing about what other fields do and having a baseline amount of knowledge in the other fields you work with, but there is no utility in spending time learning a procedure that you will never perform, never be credentialed to perform and could potentially harm patients in you attempting to learn that procedure. I don’t want my patients having lines places by residents who want to do rheum - what happens when you hit the carotid or drop a lung doing a procedure that you wanted to do because you thought it was neat?

I suppose we will agree to disagree, but suffice it to say, I think your argument involves significant hand waving.

 

[rokshana]

You need to do the other rotations to understand how the disease processes you treat are influenced by other diseases and how they crossover. You need to know about heart failure because you treat thyroid diseases that can lead to heart failure and understand what that looks like. You need to know about coronary disease because you will have diabetics you manage and need to understand the diagnostics and therapeutics involved in managing coronary syndrome. The head knowledge of understanding medicine broadly serves everyone well. That’s why it can be infuriating when you talk to a surgical subspecialist who knows their disease process well but can’t see the patient as a whole.

That is an entirely different thing from being facile in a procedure that you never do. You need to have the head knowledge about what the procedure entails, indications, the potential complications, etc. - but there is absolutely no need for you to have the hands. If you take your argument to it’s logical conclusion, you shouldn’t go on to residency in internal medicine until you’ve mastered the surgical procedures you’re exposures to in med school. The fact of the matter is that there is value in knowing about what other fields do and having a baseline amount of knowledge in the other fields you work with, but there is no utility in spending time learning a procedure that you will never perform, never be credentialed to perform and could potentially harm patients in you attempting to learn that procedure. I don’t want my patients having lines places by residents who want to do rheum - what happens when you hit the carotid or drop a lung doing a procedure that you wanted to do because you thought it was neat?

I suppose we will agree to disagree, but suffice it to say, I think your argument involves significant hand waving.

we will, because its not just about what you plan to do in the future, but what you need to know and do as an IM resident in my opinion that is important when you are actually a resident...plenty of people come into residency thinking one thing and end up doing another...most of my co residents came in thinking fellowship and ended up not and became GIM or Hospitalist or changed their minds about what fellowship they wanted to do.

 

[lulu09]

You need to do the other rotations to understand how the disease processes you treat are influenced by other diseases and how they crossover. You need to know about heart failure because you treat thyroid diseases that can lead to heart failure and understand what that looks like. You need to know about coronary disease because you will have diabetics you manage and need to understand the diagnostics and therapeutics involved in managing coronary syndrome. The head knowledge of understanding medicine broadly serves everyone well. That’s why it can be infuriating when you talk to a surgical subspecialist who knows their disease process well but can’t see the patient as a whole.

That is an entirely different thing from being facile in a procedure that you never do. You need to have the head knowledge about what the procedure entails, indications, the potential complications, etc. - but there is absolutely no need for you to have the hands. If you take your argument to it’s logical conclusion, you shouldn’t go on to residency in internal medicine until you’ve mastered the surgical procedures you’re exposures to in med school. The fact of the matter is that there is value in knowing about what other fields do and having a baseline amount of knowledge in the other fields you work with, but there is no utility in spending time learning a procedure that you will never perform, never be credentialed to perform and could potentially harm patients in you attempting to learn that procedure. I don’t want my patients having lines places by residents who want to do rheum - what happens when you hit the carotid or drop a lung doing a procedure that you wanted to do because you thought it was neat?

I suppose we will agree to disagree, but suffice it to say, I think your argument involves significant hand waving.

I personally fully agree with this. I think there was a time and place where the physician is seen more as a one stop shop (with the whole House of God-esque medicine intern essentially physically performing whatever procedure they wanted to the patient) but with the increasing sub-specialization of medicine a lot of procedures internal medicine residents were expected to do are increasingly less relevant. ABIM only requiring IV, phlebotomy, and pap smear reflects this trend away from medicine residents needing to perform every procedure. I agree that not every resident comes into residency knowing *exactly* what they want to do so I do think the opportunity to do "advanced procedures" (and here I'm broadly defining as any procedure that ABIM deems non-essential) should exist to get a flavor for it, but certainly not be required.

I personally am going into heme-onc so I made sure to do plenty of LPs because increasingly on the list of ABIM procedures LP is the only thing left that oncologists potentially *could* do, and even so it's increasingly rare. Sure, I did CVCs and tons and tons of paras -- did I think I was a better clinician because I was exposed to these procedures and I could explain the whole procedure step-by-step to the patient? Sure, maybe. Did I think it was essential? Definitely not. A lot of my cardiology/CCM peers went the other direction and did a lot of lines for practice before fellowship. I think the vast majority residents that I know who decided which specialty to do in residency, myself included, decided on the field based on the pathology and not what procedures we did in residency.

I trained in a more "inner-city" residency so we were often expected to be able to do a lot of procedures by ourselves. Having gone through the experience, I do think that in the interest of patient safety and also simply better and more expedient outcomes your everyday run-of-the-mill internal medicine resident should not be expected to perform tons of procedures. Sure, I fully recognize that not every hospital or training environment will have the luxury of having subspecialty fellows perform procedures but it's lazy and poor practice to just delegate medicine residents as the de facto back-up in the name of "training" because there is lack of staffing. I for one don't subscribe to this whole glorified bragging of "me and my senior managed a 20-bed ICU by ourselves overnight" and it "made us better doctors" BS, even though I know what it felt like to go through it.

 

[deleted547339]

I personally fully agree with this. I think there was a time and place where the physician is seen more as a one stop shop (with the whole House of God-esque medicine intern essentially physically performing whatever procedure they wanted to the patient) but with the increasing sub-specialization of medicine a lot of procedures internal medicine residents were expected to do are increasingly less relevant. ABIM only requiring IV, phlebotomy, and pap smear reflects this trend away from medicine residents needing to perform every procedure. I agree that not every resident comes into residency knowing *exactly* what they want to do so I do think the opportunity to do "advanced procedures" (and here I'm broadly defining as any procedure that ABIM deems non-essential) should exist to get a flavor for it, but certainly not be required.

I personally am going into heme-onc so I made sure to do plenty of LPs because increasingly on the list of ABIM procedures LP is the only thing left that oncologists potentially *could* do, and even so it's increasingly rare. Sure, I did CVCs and tons and tons of paras -- did I think I was a better clinician because I was exposed to these procedures and I could explain the whole procedure step-by-step to the patient? Sure, maybe. Did I think it was essential? Definitely not. A lot of my cardiology/CCM peers went the other direction and did a lot of lines for practice before fellowship. I think the vast majority residents that I know who decided which specialty to do in residency, myself included, decided on the field based on the pathology and not what procedures we did in residency.

I trained in a more "inner-city" residency so we were often expected to be able to do a lot of procedures by ourselves. Having gone through the experience, I do think that in the interest of patient safety and also simply better and more expedient outcomes your everyday run-of-the-mill internal medicine resident should not be expected to perform tons of procedures. Sure, I fully recognize that not every hospital or training environment will have the luxury of having subspecialty fellows perform procedures but it's lazy and poor practice to just delegate medicine residents as the de facto back-up in the name of "training" because there is lack of staffing. I for one don't subscribe to this whole glorified bragging of "me and my senior managed a 20-bed ICU by ourselves overnight" and it "made us better doctors" BS, even though I know what it felt like to go through it.

To piggy back on this, there is a lot of self-selection for this as you alluded to. The people doing CCM are seeking out procedures while people doing geriatrics or primary care aren’t. And, as you say, not everyone works at a big university; but I doubt many residents who go to MGH or Penn are taking small town community jobs where they’re the only doc in the hospital and do procedure after procedure. If you want to be that doc, you’re likely better served at a smaller hospital for residency. Similarly, if you want to become the worlds leading expert of ILD or sarcoidosis, a small community program probably isn’t the right place for you. I think it was wise for the ABIM to realize this.

 

[NITRAS]

I did like 60+ central lines in residency, probably 30 intubations, 1 chest tube, enough LPs and Paras to feel confident. I actually never did a thora. Its been 3.5 years, and I have not done a central line. Some days I miss them, but shoot. That is a high risk procedure, I've seen a ton of complications. I could probably do one, but it seems like you are asking for trouble.

The only in house backup I had in residency on MICU was the ED, who would come up for all intubations. All patients were called or texted to an attending. All CVCs and intubations were supervised (if possible).

I actually get to do pretty regular LP's and the occasional para if things aren't too busy, but only because I like doing something, and they are both very low risk procedures. At my institution, floor patients almost never have CVCs other than PICCs. Its better that way.

 

[throwaway1939]

If a third year resident is expected to "handle anything that walks in the door" in your CICU, then that says something about the complexity of care being delivered at your center.

In a large transplant/VAD center there needs to be somebody who can float an emergent TVP, place a PA catheter and use the hemodynamics to adjust inotropes/nipride or guide escalation to mechanical circulatory support, recognize and treat acute rejection, manage VT storm, reprogram ICD/pacemakers using device programmers, perform TEE to evaluate for ruptured pap muscle or dissection, etc.

A third year resident can't and shouldn't be trusted to do things like that, or even recognize when they are necessary. Quite simply, you don't know what you don't know at that stage of your training when it comes to managing advanced heart failure/cardiogenic shock or complicated ACS. As a first year fellow, I was still calling in upper level support for this stuff and can remember a few misses.

VADs and transplants are handled by a dedicated transplant team, otherwise, I've done nipride/dobutamine in the middle of the night. I've treated VT storm (including having anesthesia tube a dude and put him on propofol after he broke through amiodarone and lidocaine). I helped diagnose tamponade on the floor with a pulsus but the fellow refused to come in. That gentleman ended up getting a pericardiocentesis at like 6am when the interventional fellow came in.

I can't do device stuff, I can't do TEE, and for these things, I've called the fellow. But you don't need a fellow to know when to start dobutamine.

 

[CCM-MD]

But you don't need a fellow to know when to start dobutamine.

Maybe. Maybe not.

The Dunning-Kruger effect is abundant. You don't know what you don't know despite how much you think you might know.

 

[NITRAS]

Love the starcarft. @CCM2017 .

Is that Maru?

 

[Psai]

Maybe. Maybe not.

The Dunning-Kruger effect is abundant. You don't know what you don't know despite how much you think you might know.

Amazing.