Is there a difference in the way IM is practiced at premier instituations vs others?

[Gorne]

I love medicine, however at the hospital affiliated with my medical school IM is a ****-show with 5,000 IM residents essentially doing secretarial work 90% of the day. The attending comes in to round, essentially does the diagnosing/management himself, pawns off the referrals/consults to his underlings then takes off.

Is there more autonomy / diagnosing/ critical thinking at the premier IM residencies? I guess I'm looking for the opinion of someone who did rotations at programs like my home institution and did rotations at the ones with 250+ average step scores are needed for interviews.

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[Gorne]

I guess I’ll ask the question another way. With an interest in medicine, am I doing myself a disservice by not doing an away where I can see how medicine Is practiced at another institution, one that aligns more with my credentials, unlike my home institution.

 

[ABatOutofHeck]

Well, I can't speak to your institution, but things are certainly different elsewhere. At both my medical school, my residency hospital, and my fellowship hospital, trainees are expected to take the lead on diagnosis and management, with attendings playing a supervisory and teaching role. In residency, in particular, the senior residents ran the show. There was also an emphasis on appropriate supervision, with attendings in house for the business day while they're on service and an overnight person who's your assigned back-up on call. Your home institution sounds sub-optimal for training, and I think it would be worth trying to go elsewhere.

 

[Psai]

Well, I can't speak to your institution, but things are certainly different elsewhere. At both my medical school, my residency hospital, and my fellowship hospital, trainees are expected to take the lead on diagnosis and management, with attendings playing a supervisory and teaching role. In residency, in particular, the senior residents ran the show. There was also an emphasis on appropriate supervision, with attendings in house for the business day while they're on service and an overnight person who's your assigned back-up on call. Your home institution sounds sub-optimal for training, and I think it would be worth trying to go elsewhere.

I made many of the decisions which I ran by the senior resident and they kept the attending in the loop. Decisions were made, consults called and orders entered before rounds. Rounds focused on learning by going through seminal papers and discussing important topics.

 

[utmua78]

this sounds like my IM core rotation in a community hospital when dealing with private attendings admitting to resident service. Then i did a SUB-I at a bigger program and completely loved the rotation and the education. deffinitely do an away, and also inform your clerkship director about the poor quality of education that youre receiving,

 

[Instatewaiter]

I love medicine, however at the hospital affiliated with my medical school IM is a ****-show with 5,000 IM residents essentially doing secretarial work 90% of the day. The attending comes in to round, essentially does the diagnosing/management himself, pawns off the referrals/consults to his underlings then takes off.

Is there more autonomy / diagnosing/ critical thinking at the premier IM residencies? I guess I'm looking for the opinion of someone who did rotations at programs like my home institution and did rotations at the ones with 250+ average step scores are needed for interviews.

At top IM Programs there is more autonomy than you would know what to do with... often to the point that you would feel like you were doing everything by yourself beyond your capabilities. Now, it isn't the wild west like it once was but even still, these programs are set up to have tons of guided autonomy

 

[IMreshopeful]

Eh there’s a balance. The program you are describing sounds terrible - sounds like a patient mill geared towards using the residents as free labor without any education.

On the other hand I do know of programs which operate on the other extreme where they round for hours in what is essentially academic masturbation. There’s a happy medium.

I liked my program - workflow was typically - preround, orders/notes/consults mostly done by the time attending starts rounds, rounds are mix of decision making shared between residents and attending with pure education, finish up remaining work in early afternoon and as rounds progressing, then do more education/teaching/stuff until signout time. Call days tended to be longer and busier due to having to do and staff admits throughout the day.

I don’t miss general medicine much, but there is a way for the day to be both efficient and educational.

 

[ShuperNewbie]

I would agree with the poster, that a happy balance is key. I really like the way NYU does stuff. Rounds are limited to roughly 1 hour each day and are usually done in the context of teaching med students/ interns about fundamental concepts in medicine and how to apply them using the new patients as an example. Attendings function as consultants and are always available when you need them, thus the resident is allowed a happy medium of self titrating the amount of autonomy they are comfortable with. And in terms of management decisions, as the resident you absolutely have fully autonomy with the patients. It's actually not uncommon for attendings or even consultants to defer to the resident regarding management decisions, often saying things like "this is what I would do but the decision is ultimately up to you and if you want to do X then that's perfectly fine." They'll stop you short if your decision might cause harm though lol

 

[Trogghunter]

I did some community med school rotations where residents did 99% of everything, every decision made, period. We also had a prison ward that attendings never went in and before the hospital had EMR, the med students ran it and because everything was on paper. No lie and this was in the past decade. It varies depending on where you are. If you have residents and you're just using them as secretaries but you're leaving at noon every day, that's living the dream because you've #madeit and you're #winning. Not a good place to train, but most university hospitals are not like that, "university affiliated" hospitals are just community places where attendings don't really have any obligations to teach, so most don't. It's very different at university hospitals, that's where you see academic medicine more vs practical medicine...ie focusing more on horses rather than hunting zebras.