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I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
 
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Crayola227

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Sounds like you need to find a new program.
I would love to find a new program. But I was under the impression that it is not possible unless you are fired or experience a serious life changing event. Any advice?
 

Crayola227

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I would love to find a new program. But I was under the impression that it is not possible unless you are fired or experience a serious life changing event. Any advice?
Read some of my other past posts.

1) UNDER NO CIRCUMSTANCES SHOULD YOU ROCK THE BOAT OR DO ANYTHING TO PUT THIS POSITION AT RISK.
If anything happens to your job here, the chances that you never again practice clinical medicine again is terminally high.

2) You can read on SDN about switching residencies. I don't think it's at all advised for you.
The circumstances under which this is advised is usually when you need to change *specialties*, or that the malignancy of the program is such that there is really no way you can finish there anyway. If they are not trying to boot you out, you need to try to stay. This is Willa Wonka's Golden Ticket to the Chocolate Factory or a Winning Lottery Ticket. Big deal consequences for the rest of your life, try to hold onto it.

3) Some degradation of mental and physical wellbeing is unavoidable in residency.
-The key is, can you increase self care and find ways of coping that will allow you to function at sufficient, if not optimal, levels? I have a post recently about resident self care strategies.

4) Educational Quality
You will need to find ways to cope here as well. SDN has threads and strategies for how residents can try to be proactive and get more out of their experiences. It sucks that the didactics are lacking, that is more easily adjusted for by self study in the form of reading and board review materials.

Tread lightly.

As you get settled, you could find out if you could help with/head up informal journal club, board question review sessions after work, etc. Helping organize this should be what the PDs and Chiefs are doing, but might not be. Just because they are not, does not mean they will take kindly to you trying to run a noon conference or something. But if you do something little it might be OK. Every little didactic is a didactic.

If this is intern year, get settled first. The first part of intern year is learning how to get things done in the hospital system efficiently, even if otherwise what you are doing is not trying to maximize the quality of the care you are providing for that time.

Don't challenge your uppers right now. It's OK to ask them why abx X and not Y, but in a way that is just trying to understand what *they* think is best, or to them sharing teaching points they might have not made otherwise. This can open things up to more discourse and learning. If they are not open to that, just let it go.

If this program is accredited, you work hard, keep your head down, don't make waves, use SDN and mentor advice to get the most that you can from your training years, and use proven board review strategies, you will become board certified. Will you be ready to be an attending? That's awfully complex. I like to think in an accredited program where you work hard and don't take pains to lie on the surveys re: its accreditation, that somewhere between before graduation to not too long after you will become competent. Have other competent attendings emerged, even if with a little time after graduation, from this program, in some environment? If yes, you are looking to recreate that success.

I don't mean to excuse what you're getting education-wise here, but you have to make the most of the hand you're dealt, and to some extent have faith even in a half baked process to get there, even if it's going to be harder.

Good luck, I think there's a way to succeed, improve yourself, become competent, and maybe even improve this residency a little before you leave. But for now, just focus on survival.
 
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Read some of my other past posts.

1) UNDER NO CIRCUMSTANCES SHOULD YOU ROCK THE BOAT OR DO ANYTHING TO PUT THIS POSITION AT RISK.
If anything happens to your job here, the chances that you never again practice clinical medicine again is terminally high.

2) You can read on SDN about switching residencies. I don't think it's at all advised for you.
The circumstances under which this is advised is usually when you need to change *specialties*, or that the malignancy of the program is such that there is really no way you can finish there anyway. If they are not trying to boot you out, you need to try to stay. This is Willa Wonka's Golden Ticket to the Chocolate Factory or a Winning Lottery Ticket. Big deal consequences for the rest of your life, try to hold onto it.

3) Some degradation of mental and physical wellbeing is unavoidable in residency.
-The key is, can you increase self care and find ways of coping that will allow you to function at sufficient, if not optimal, levels? I have a post recently about resident self care strategies.

4) Educational Quality
You will need to find ways to cope here as well. SDN has threads and strategies for how residents can try to be proactive and get more out of their experiences. It sucks that the didactics are lacking, that is more easily adjusted for by self study in the form of reading and board review materials.

Tread lightly.

As you get settled, you could find out if you could help with/head up informal journal club, board question review sessions after work, etc. Helping organize this should be what the PDs and Chiefs are doing, but might not be. Just because they are not, does not mean they will take kindly to you trying to run a noon conference or something. But if you do something little it might be OK. Every little didactic is a didactic.

If this is intern year, get settled first. The first part of intern year is learning how to get things done in the hospital system efficiently, even if otherwise what you are doing is not trying to maximize the quality of the care you are providing for that time.

Don't challenge your uppers right now. It's OK to ask them why abx X and not Y, but in a way that is just trying to understand what *they* think is best, or to them sharing teaching points they might have not made otherwise. This can open things up to more discourse and learning. If they are not open to that, just let it go.

If this program is accredited, you work hard, keep your head down, don't make waves, use SDN and mentor advice to get the most that you can from your training years, and use proven board review strategies, you will become board certified. Will you be ready to be an attending? That's awfully complex. I like to think in an accredited program where you work hard and don't take pains to lie on the surveys re: its accreditation, that somewhere between before graduation to not too long after you will become competent. Have other competent attendings emerged, even if with a little time after graduation, from this program, in some environment? If yes, you are looking to recreate that success.

I don't mean to excuse what you're getting education-wise here, but you have to make the most of the hand you're dealt, and to some extent have faith even in a half baked process to get there, even if it's going to be harder.

Good luck, I think there's a way to succeed, improve yourself, become competent, and maybe even improve this residency a little before you leave. But for now, just focus on survival.

Thank you for this very thorough reply. I anticipated that I would just have to suck it for now. The training for my previous profession before med school involved a bull**** "problem-based learning" curriculum that was mostly self study with little direction or input from crotchety faculty. I was hoping to never go through that sort of experience again. Med school was a much more productive and pleasant experience. I appreciate your sensitivity for my concerns.
 
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You've been there like 6wks now?

Just keep grinding for a few months before you declare your time wasted, surely they didn't just change all the rounding as soon as your audition was over last year, right? Focus on the positive and keep your career progressing

The interview didn't involve rounds. The PD and residents emphasized their passing board scores and we did attend a morning report, but I don't recall them mentioning that interns do not go to morning report, or very many didactics in general. The program appeared a lot more academic at first glance. I should have asked more questions or taken a second look, but I assumed every residency would emphasize evidence based medicine, guidelines, journal club, etc.
 
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Sounds ****ty. Now get over it. You can learn in this environment because it comes with sick patients. You won't be spoonfed so read and read. A year from now, you'll be in charge. The attendings won't change reasonable plans in the am.

Oh, and BTW, you may find that some of those old school ideas and less expensive drugs work. Guidelines are a starting point. Do you know the resistance patterns specific to your lab (I bet someone does)?

Replace journal club with journal watch. Replace teaching rounds with UTD. When you are a 2, teach your interns. Do procedures. See sick people.

Don't transfer. Don't tell the PD that you think everyone is dumb. If you plan to subspecialize, these years aren't particularly important.
 

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I agree with gastrapathy and Crayola above. You don't want to make waves or do anything that's going to jeopardize you graduating and thus actually having a career.

Sorry it hasn't turned to be what you had envisioned but to be honest, I think most of us had somewhat similar thoughts about either med school, residency/fellowship or just medicine in general.

You have one job now, to become a competent internist so use whatever resources you can get and be thankful you are at a location that provides good pathology to learn from.... that's not the case everywhere.

I had somewhat similar feelings during residency as while we had a good number of "didactic" sessions, most were resident run and honestly, a good chunk of learning medicine is actually learning the art of it while on the job, fine tuning what you do by seeing different presentations of the same disease and different management styles. You take all that, ready/study on your own and synthesize it into your own practice style.
 

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Some great advice here.

You can learn in this environment because it comes with sick patients. You won't be spoonfed so read and read. A year from now, you'll be in charge. The attendings won't change reasonable plans in the am
Some really struggle with the transition from didactic-based to more clinical-based education, as it can be overwhelming. It's time to start developing those adult learning skills, the studying and information gathering will be up to you, not some attending giving a PowerPoint.

The onus is on you as a trainee physician to read about your patients each day - know the pathology, physiology and typical disease course. Try to anticipate complications that can arise and consider how you can treat or avoid them.

Finally, we are entering a new era of medicine with smarter resource allocation. It makes no sense to prescribe an expensive brand name antibiotic when a generic penicillin will get the job done. Medical schools notoriously struggle teaching this (and residencies/fellowships) - bear in mind that procedures, labs and medications cost money so shot-gunning without too much thought may no longer be the best approach.
 

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I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
At this point, in August, I am unsure of how much of it is truly an issue with the program vs you getting acclimated.

For example, I personally doubt that there are no didactics whatsoever for the interns in an accredited program. Presumably, the program has some form of conferences. You mention morning reports in your post but state that the interns don't typically go. Is it that the interns don't *ever* go? Are they not invited? Or is it that the interns on certain busy rotations such as ICU (which you happened to have early in the year) don't go? Or that interns in the beginning of the year when they're overwhelmed tend not to go? Perhaps the conference schedule is truncated the first few months of the academic year because they know people are overwhelmed, but will become more comprehensive in Sept or so? All of the above are things I've seen at my former program and others. Have you had any electives yet to see what your conference attendence might be on those rotations?

Otherwise, the lack of pre-rounding and the lack of explicit teaching based on papers/guidelines is actually not THAT abnormal for really early in the year, especially with busy rotations. Why? Because right now you're learning how to keep your head above water. So is your second year! They should be pre-rounding with you, but if they're struggling to review everything on their own in the morning, dedicated didactics can fall by the wayside. It tends to get better as the academic year moves on. Similarly, rounds in the beginning of the year tend to get mired in minutia: The attending often wants to go over every specific choice of insulin dose, lasix regimen, antibiotic choice, hell, even electrolyte repletion. They might not have the time to actually sit you down and go over the 15 competing sets of lipid guidelines. As the year moves on and they get more comfortable that you're capable of handling the simple things, that tends to diminish the details of the discussion and leave more time for teaching.

Bedside rounds vs table rounds is a stylistic difference with +/-s both ways. I personally preferred primarily table rounds because it gave us the chance to more comprehensively review things in a controlled environment. Obviously bedside rounds are necessary for any new (or ill) patient, but the attending can often see followups on their own. By the way, I highly doubt that the attendings aren't seeing the patients after you discuss them as a team. It would be flat-out fraud for them to be providing care in an inpatient setting without physically laying eyes on the patient daily. Fraud to the point that if you could actually document this occurrence, the federal government will give you a cut of the proceeds to report it. Much more likely is they're trying to be respectful of your time by seeing the followups on their own.

The one point I'll absolutely give you is the frustration with the "quagmire of social issues, bureaucracy, and arbitrary policies". Unfortunately though, that's a reality with modern medicine that you'll find in a lot of places. If you find a solution to it though, let me know.
 
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Med school was a much more productive and pleasant experience....Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
of course med school was a more pleasant experience...you didn't have to really be responsible for things and certainly didn't have to do the drudge work that is really part of the responsibilities of an intern... like dealing with the quagmire you note in your post.
 
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honestly, as you progress the social aspect of medicine is not that difficult. Right now your senior should be helping with the big picture plan.

when u admit a pt u should be thinking what will this pt likely need to safely discharge them, ask them their functional status and living situation as u are admitting them, will they need insulin teaching, think of PT evaluation early. If pt needs a SNF, make sure to tell pt early on that u think they will need a SNF, and all u have to do is send a referral to case manager and it's done, U don't need to discuss with pt which SNF they will go to (some pts have strong opinions about not going to certain SNFs), let the case manager do that.

Problem is if u don't assess what the pt will need for discharge from the beginning, it seems like a lot of work to do at the end.
 
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OP, might you consider giving your colleagues and program a chance to show what they are made of? You've barely been there for 1.5 months??

I also wonder to what extent your expectations clash with reality, and if any other program would in fact suit your needs as your number 1 pick can't seem to do.

The grass may not be greener, and you might look back on your current program as a lost paradise.

Keep in mind that while seemingly a long ways down the road, the point of residency is to graduate and become a doctor (which may involve more learning some stuff on your own at the current program). But if you graduate and you do right by your program and get good recs at the end, who cares?

Don't lose the forrest for the stupid trees.
 
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Not sure if I am on the same page with OP. He/she expect an automatic LP with pt who are found down or always sticking with the abx guideline?

Not sure if OP knows that all clinical scenarios are different, and especially in their underserved environment, knowledge of what "works" shows clinical acumen rather than cookbook medicine.

I got a feeling OP is more cook book medicine than "evidence based"
 

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does your program has more than one site? Lot of programs have more than 1 site and they benefit from learning from different populations. Sure 2 lectures so far sounds bad but most programs dont start full time didactics until 2nd block to give time for residents to get acclimatized to the system. County hospitals typically take care of underserved population and I am sure workload is higher there compared to privately owned hospital. But there is nothing that can stop you from learning what is right for the patient. Lot of times, residents think mediocrity is okay and live with it and end up being mediocre graduates. U have been able to appreciate that management of patients needs more EBM and I would encourage to continue doing it. May be if u have another site, u can use those knowledge to better use.
 

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I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
Yeah that "warmth" of the residents and faculty and "commitment to an underserved and international population" always fools me as well... Seriously how naive can you get?

If you don't go to a University-based program where there is full-time faculty and medical students, you are not likely to get good teaching.

There's nothing you can do.
 
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Crayola227

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Yeah that "warmth" of the residents and faculty and "commitment to an underserved and international population" always fools me as well... Seriously how naive can you get?

If you don't go to a University-based program where there is full-time faculty and medical students, you are not likely to get good teaching.

There's nothing you can do.
there's plenty of community program trained physicians who could beg to differ, some from highly regarded medical schools with highly regarded programs

in fact, I think a lot of the academic programs have descended into resident-run meat markets, and some of the community programs are really set up to be a teaching service

I think a lot of places have lost perspective on the balance between service and learning for residents, and it broad swaths doesn't cut it
 

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Yeah that "warmth" of the residents and faculty and "commitment to an underserved and international population" always fools me as well... Seriously how naive can you get?

If you don't go to a University-based program where there is full-time faculty and medical students, you are not likely to get good teaching.

There's nothing you can do.
Really? that sounds like a gross overgeneralization.
 

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there's plenty of community program trained physicians who could beg to differ, some from highly regarded medical schools with highly regarded programs

in fact, I think a lot of the academic programs have descended into resident-run meat markets, and some of the community programs are really set up to be a teaching service

I think a lot of places have lost perspective on the balance between service and learning for residents, and it broad swaths doesn't cut it
It also depends on what type of doctor you're training.

I would put FM grads from the community programs in my state up against the university FM grads every day of the week. Same thing with IM.

Would I want my neurosurgeon to train at a 300 bed hospital? Maybe not. But I'd rather my PCP not having taken a back-seat on rotations in residency to other services.
 
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Yeah that "warmth" of the residents and faculty and "commitment to an underserved and international population" always fools me as well... Seriously how naive can you get?

If you don't go to a University-based program where there is full-time faculty and medical students, you are not likely to get good teaching.

There's nothing you can do.
For a second, I thought I posted that...yikes.

It's been 1.5 months! I typically would expect hugs and kisses from colleagues by no earlier than 4 months of working together.
 
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Winged Scapula

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It also depends on what type of doctor you're training.

I would put FM grads from the community programs in my state up against the university FM grads every day of the week. Same thing with IM.

Would I want my neurosurgeon to train at a 300 bed hospital? Maybe not. But I'd rather my PCP not having taken a back-seat on rotations in residency to other services.
Absolutely.

That's why RRC has rules about training sites and patient volume. As a matter of fact, one very common reason programs, especially surgical ones, get put on probation is patient: resident volume. If you don't have the numbers/cases, you won't get experience.

As someone who left academics and is now in PP in the community (with an academic appointment still), I see many of my colleagues with Ivy League/top notch credentials doing the same. Teaching can be good or bad regardless of where you are; I think its more a function of where/how the faculty trained and personal attributes in terms of whether they know how to teach.
 
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Resident [Any Field]
Been at it a few more months now. And many of the attending physicians are not talking to or examining patients. My suspicions were confirmed on general wards by other residents and attendings when I asked, some of the attendings do not see the patients everyday. I have had an ICU attending that only stares at the patient through the glass while we give a short presentation, preferably only 1-2 lines. He never walked into a room or talked to a patient or talked to family members. In one of the specialty clinics today, residents and med students were allowed to sign out followup patients and I never saw the attending get out of his chair. The attending did not come to see or talk to my patient. I am not even sure if a resident or fellow followed up after the med students; I did not, nor was I instructed to do so by senior residents/fellow/attending. I am not sure what the rules are regarding attending supervision, but this does not feel like best practice.
 

Mad Jack

Critically Caring
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Jul 27, 2013
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I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
Are monthly lectures even kosher with the ACGME?
 

Mad Jack

Critically Caring
5+ Year Member
Jul 27, 2013
35,680
65,469
4th Dimension
Been at it a few more months now. And many of the attending physicians are not talking to or examining patients. My suspicions were confirmed on general wards by other residents and attendings when I asked, some of the attendings do not see the patients everyday. I have had an ICU attending that only stares at the patient through the glass while we give a short presentation, preferably only 1-2 lines. He never walked into a room or talked to a patient or talked to family members. In one of the specialty clinics today, residents and med students were allowed to sign out followup patients and I never saw the attending get out of his chair. The attending did not come to see or talk to my patient. I am not even sure if a resident or fellow followed up after the med students; I did not, nor was I instructed to do so by senior residents/fellow/attending. I am not sure what the rules are regarding attending supervision, but this does not feel like best practice.
In all fairness, "door rounding," as we called it, was a common practice when I was an employee at one of the top IM residencies in this country. You'd try and tell an attending, "but the patient very clearly and visibly has X" and they would send a resident to look at the patient and not buy it if it wasn't in line with their existing treatment plan, despite having never looked at the patient after admission except through the glass. Some attendings we're much better, but some were very... Ugh.
 
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AdmiralChz

ASA Member
10+ Year Member
Sep 8, 2008
3,391
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Attending Physician
Been at it a few more months now. And many of the attending physicians are not talking to or examining patients. My suspicions were confirmed on general wards by other residents and attendings when I asked, some of the attendings do not see the patients everyday. I have had an ICU attending that only stares at the patient through the glass while we give a short presentation, preferably only 1-2 lines. He never walked into a room or talked to a patient or talked to family members. In one of the specialty clinics today, residents and med students were allowed to sign out followup patients and I never saw the attending get out of his chair. The attending did not come to see or talk to my patient. I am not even sure if a resident or fellow followed up after the med students; I did not, nor was I instructed to do so by senior residents/fellow/attending. I am not sure what the rules are regarding attending supervision, but this does not feel like best practice.
Yeah this stinks, but hardly a rarity in academic practices unfortunately. On the positive this puts more emphasis on your role as a provider to make sure everything is going well and follow up on treatments. You will need to step up and be a physician, you can’t control what other people are doing.

When you are an attending yourself, remember how this feels and make it a point to take a more active role in patient care. Also, don’t be afraid to take an active role in medical student education - they will greatly appreciate it.
 

Gastrapathy

no longer apathetic
Lifetime Donor
10+ Year Member
Feb 27, 2007
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This is why no one finds the VA scandal surprising. It's been a while, but I had one attending who would only ever phone round with the residents, always in his car, usually with the top down.
 
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Raryn

Infernal Internist / Enigmatic Endocrinologist
10+ Year Member
Apr 25, 2008
7,757
6,722
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Attending Physician
Been at it a few more months now. And many of the attending physicians are not talking to or examining patients.
My suspicions were confirmed on general wards by other residents and attendings when I asked, some of the attendings do not see the patients everyday. I have had an ICU attending that only stares at the patient through the glass while we give a short presentation, preferably only 1-2 lines. He never walked into a room or talked to a patient or talked to family members.
This is technically legal, as long as they lay eyes on the patient every day. Not good patient care, but legal.

In one of the specialty clinics today, residents and med students were allowed to sign out followup patients and I never saw the attending get out of his chair. The attending did not come to see or talk to my patient. I am not even sure if a resident or fellow followed up after the med students; I did not, nor was I instructed to do so by senior residents/fellow/attending. I am not sure what the rules are regarding attending supervision, but this does not feel like best practice.
Assuming this is not a VA (where billing rules are quite different), this is not legal and is in fact fraud if true.

There is a limited exception in primary care only, where for a follow-up visit in a resident clinic the attending is allowed to not physically see the patient and still get paid. The resident must be at least in the second half of intern year and no higher than a level 3 visit can be billed. This exception does not (and cannot) apply to specialty clinics or to medical students. In fact, no documentation by medical students except the past history/family hx/social history/review of systems can count for billing without being independently verified by a physician. The only way to get around this without doing a full note from scratch in addition to the students in the EMRs I'm familiar with is if you have the student act as a "scribe", which might be reasonable if you repeat the relevant portions of the H+P... and fraud if you don't. I mean, you can also just copy/paste the student note in its entirety or have the student log in under your name, but those are both also fraud.

As an intern in October, the attendings must physically see all of your clinic patients. They don't have to touch them, but they can't just sit at their computers the whole time in a different room. In a specialty clinic, the attendings must physically see all of your clinic patients even if it is the last day of your training.

I'm more confused over how medical students are reportedly seeing patients on their own. They can't put in orders. Are the attendings putting in orders based on student reports without verifying anything on their own? That's just stupid if true.
 

DoubleBogey

2+ Year Member
Jul 11, 2017
244
135
Status
Attending Physician
Squeaky wheel gets the grease, keep your head down and learn from your patients
 

jkc17

2+ Year Member
Sep 21, 2017
12
2
Status
Resident [Any Field]
I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
I recently matched into my #1 pick for IM residency, but since starting my intern year, I am disappointed in the quality of education provided to residents and the quality of the care provided to patients at my new hospital. During interview season I loved the warmth and friendliness of the residents and faculty, commitment to an underserved and international population, and diverse pathology encountered. All those things are still true of the program and everyone has been super nice and helpful if I ask for something. Sure the work is hard and the days are long, but I do not feel too overworked or overstressed. I feel under-learned.
During the interview, I guess I failed to grasp that this program is very clinical with very minimal emphasis on academics. There are almost no didactics for interns. I've been to two lectures in two months, that were not very enlightening. There are usually no pre-rounds and we only do table rounds with the attendings unless it is a new patient. It seems that most attendings do not see the patients after that first encounter, unless you tell them you are worried or need help. There is almost no mention of evidence based medicine, guidelines, or studies. Most of the residents went to medical school here and follow the instructions of the attendings blindly and therefore, do not teach much themselves or discuss studies/guidelines. I trained and worked in another inpatient healthcare specialty before medical school, so I notice when care isn't exactly considered "best practices." For example, a co-intern giving me sign out for ICU and thinking it's ok to skip an LP for someone found down/acutely encephalopathic with fever or using cheaper antibiotics over evidence based drugs of choice, because the attending said so. When I have tried to voice my concerns, most people just say one of these responses: "That's just how this program works." "This is county hospital." "You will eventually drink the Koolaid and love it." Also, It doesn't help that for almost every patient you have to waste time and work through a quagmire of social issues, bureaucracy, and arbitrary policies via the social worker, care coordinator, utilization review personnel, and hospital administration, all with overlapping responsibility and who give you conflicting advice.
Finally, I talked with a fellow who did not complete his general residency here and they agreed that the education quality was not very good. They also commented that the resident performance was not as strong as other places they had trained and it seemed that IM residents were receiving training that would only prepare them for success at this program's hospital.
At my medical school with IM, we did walking pre-rounds with residents and walking rounds with attendings everyday. We had morning report and lunch time lecture every week day. I learned a lot everyday. Now I feel like I am working without using my brain or learning anything new. I almost never observe attendings providing care or gain insight from them. I am worried I will not be a competent physician when I complete this residency.
So I know I can't switch residencies and I know shouldn't quit. But I am just wondering if anyone else has felt this way and how (or if) they addressed this problem. The frustration is overwhelming at times and I am starting to become clinically depressed (positive SIGECAPS). Most other residents seem to be happy here, but they are mostly unfamiliar with other programs and will likely work in this hospital or system. Since I am new the area and the hospital, I still feel like an outsider and that it would be inappropriate to say anything. I am worried that if I voice my concerns to the PD, I will be viewed as a complainer or trouble maker.
I feel like I could have written this post. I also came from an academic hospital with morning report, noon conference, and research team meetings. I saw the attendings, PD and chair get to know the residents on a first name basis. I, too, decided to explore and matched at a place where resident education is not a priority and faculty is less engaged that I expected. I also am pretty depressed, but I’ve accepted the circumstances. I listen to podcasts in the car and read journal articles on my own. I have my own reading schedule. It’s not what I had hoped for when I ranked this program, but it does make me feel better about my circumstances
 

Perrotfish

Has an MD in Horribleness
10+ Year Member
May 26, 2007
8,088
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Squeaky wheels can also be replaced, especially with a year to year contract.
The appropriate alternate metaphor is "the nail that sticks up will be hammered down"

Actual, literal wheels are not replaced just because they squeak.
 

Siggy

15+ Year Member
Oct 27, 2004
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The appropriate alternate metaphor is "the nail that sticks up will be hammered down"

Actual, literal wheels are not replaced just because they squeak.
True... but I've never had my wheels squeak. Break pads, on the other hand...
 

DoubleBogey

2+ Year Member
Jul 11, 2017
244
135
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It basically means if you’re making a lot of noise, they are going to make you quiet - either by giving you more work (more intensive duties, presentations or finishing learning modules etc). When you signed your contract you’ve basically married them, which to go through a divorce would be very expensive (career wise) - in sickness and in health
 
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Siggy

15+ Year Member
Oct 27, 2004
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It basically means if you’re making a lot of noise, they are going to make you quiet - either by giving you more work (more intensive duties, presentations or finishing learning modules etc). When you signed your contract you’ve basically married them, which to go through a divorce would be very expensive (career wise) - in sickness and in health
Thank you... I know the meaning behind both sayings.

It's also a lot cheaper for the program to get rid of a resident than for a resident to get rid of a program. One thing that always comes up with these threads is the seeming lack of understanding of a Pyrrhic victory.
 

Keona

10+ Year Member
Jul 14, 2008
479
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If you're not happy then help make changes to the program. I would wait until you are well established in the program, look up the resources for antibiotics, find the antibiogram for your hospital, etc. You can refer to it while you're presenting. Eventually others may come to your way of thinking. If you and other residents are not happy with the teaching quality then help to change it. Leadership positions and committees and program review are required by the acgme, volunteer for some of those and voice your opinion. I don't know if you all have done your in training exam yet but we do extra study time focused on review material around that time of the year in addition to our normal didactics. As an intern I did not get to attend didactics at all on some rotations, as a 2nd and 3rd year I am able to attend and we have been able to positively change some of the teaching in our program. Being a squeaky wheel and only squeaking is not going to help create change, being a squeaky wheel with a strong group of coresidents who suggest, strategize, and implement the change will create positive results. We have worked for 3 years to be able to create small changes over time that I think are making a difference and will make a larger difference in the years to come.
 
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