HomerSimpson said:
I have a med school classmate who did his residency at UAB(in Birmingham) who told me that it was pretty malignant. Mainly it had to do with work hours. I have also heard that Duke's program is pretty tense. One of my old cardiac faculty told me that if pre- and post-op evals were not done on time, it would reflect on your evaluation to the point of suspension or termination from the program. Can anyone confirm this?
Duke may have been that way at one time (I don't really know) but there are no threats of suspension or termination for pre and postops. I guess if you call a new fridge and beverage bar in the office and sectional leather couch and plasma screen TV in the lounge tense, then Duke is tense.
Duke recently developed an online checklist for postop checks that is available from any computer in the hospital or via a secure connection from home, or from the wireless iPAQ issued to all residents. Postops need to be done within 48 hours unless the patient is discharged before then. Postops on weekends from Friday cases are covered by the weekend call team. Recently, it was brought to the residents' attention that the postops on the weekends weren't consistently being done. The administration allowed the residents to deal with the situation and the call coverage was voted upon by the residents. Postops from cases done by CRNAs are done by CRNAs. Rarely, a resident will go to do a postop and find that a CRNAs already did it, because a CRNA was in for part of the case.
At Duke, preops from patients coming from home are done in the preop screening clinic. These evaluations are very complete. Preops for inpatients are done by the person who is assigned that room for the next day. Occasionally the schedule will change in the evening after the resident looks at their schedule and has gone home for the day, with an inpatient added. A decent amount of the time, those are inpatients who are rescheduled and their preop is already done. Other times you look up some info from home and just fit in the paperwork before surgery. CA-1s tend to have a majority of same day admissions, whereas CA-2s have more inpatients because they are doing subspecialty rotations where the patients are sicker.
If someone consistently wasn't doing their work with either I think it would negatively impact your evaluation at any program. It's irresponsbile and unprofessional to do an anesthetic on a patient that you're responsible for preoping without either doing the preop or having someone else do it and reviewing that info.
A simple example of this would be a patient who had a significant history of postop nausea and vomiting. You don't do the preop or review the info, so you don't give any prophylaxis. Postop the patient has horrible N/V that isn't responsive to zofran and requires multiple agents. Basically that patient is suffering because you didn't do your work. If they were supposed to go home afterwards, now they will be admitted because they can't hold anything down.
Another example would be a patient who had a history of difficult intubation that you don't know about because you didn't review their old OR records. You put them off to sleep are able to ventilate, but can't intubate them. Eventually they are intubated after multiple attempts and postop have significant sore throat, hoarseness that take weeks to go away or may even be permanent. Or even worse you can't ventilate or intubate them and they have an emergency cricothyroidotomy. If you had done your work and reviewed their records you might have elected to do an awake fiberoptic from the beginning and none of that would have happened. The attendings will review the patient's history, but they run more than one room and rely on the residents to know their patients.
I could go on and on with examples, but the point is clear. The ramifications of not doing preops goes much further than potential discipline by your program. It speaks of your professionalism as a physician and is essential to ensure patient safety. In addition, the ACGME has now added professionalism to one of the core competencies that residents (all fields) are required to be evaluated on. In addition, when you are looking for jobs what is your program going to say in it's recommendations for you if you consistently didn't do your postop checks and had incomplete or missing preops?? Are they going to lie and risk having their reputation diminished when they have no reason to think that your behavior will change after graduation? Probably not!
There may be differences between how programs handle pre and postops. This may factor into workload and hours and would be something good to ask about on interview. But be wary of any program where postops aren't getting done, because this can threaten the programs accreditation.
