This is Residents' running hospital. I tell you how the sign out works in my hospital:
- 5:00 pm public speakers will inform sign out
- All residents have to attend to sign
- 5:10 A senior resident (3rd year resident on call) sit in front of us a as chairman. Then he/she will asks residents on call on each floor how many new admissions and transfers. You have to report quickly like age, gender, CC, Diagnosis, plan, pending issues for each patients. This takes around 20-30 minutes.
After finishing new admissions and transfers, each of us has to report how many patients each of us currently manages, gives quick and short report to the senior resident. There are more than 20 residents for each year in my program, so guess how long this takes.
The sign out time is at least 45 min in my program but most of them are more than 1 hour.
After public sign out with the senior resident is individual sign out, that is I will sign out my patients to the intern on call in my floor.
That is an extremely inefficient manner in which to run rounds. Unless you are on call for the night and cross covering other services, what difference does it make what's going on with *everyone's* patients? I suspect this habit is a left over from the old days when it didn't matter how long you were at work.
During the working time, nurses will never leave you work, that why it takes a long time to write progress notes (average 7 patients, maximum I have is 14 patients).
We've all had to deal with that. But there comes a point in which you have to be more efficient.
Perhaps you just wanted to vent here and don't really want some solutions, but I'm going to give them to you anyway.
I'm still confused about why it takes 4 hours to write notes on 7-12 patients, when they have already been examined, you already have the data and you are off service. Even MICU notes shouldn't take you more than 15 minutes per patient (and yes, I realize medicine notes are longer than surgery notes). If your notes are simply to document that someone has seen the patient, then it makes little sense to me to write a typical medicine note full of differentials, etc. when you have already rounded with the attending and have the diagnosis, have the plan, etc.
Here is what I suggest:
1) if you are writing notes in the charts (ie not via an EMR), gather some blank notes for each patient:
- as you see the patients in the morning, jot down a few pertinents from the exam, on the blank note;
- when you gather the vitals, put those in;
- when labs come back and you are checking them, add to your note;
- as you round with the attending, put in the Assessment and Plan (either while on rounds, while he/she is droning, or later if you think this would get you in trouble);
- take your notes to conference, heck, even lunch with you, and flesh them out or at the very least, while in sign out and they are talking about someone else's patients.
Even if the above is impossible, I'll bet you can at least do the first 3 and then when the day is over, finish the note. This is a time honored method for US students, who then put their finished note in the chart on rounds.
2)
After you sign out your patients at 6 pm, turn your pager off. Nurses should be calling whomever is on for the night. Not you. Its hard in the beginning to tell them this, because you want to be nice. You want everyone to like you. But you are working 16-17 hour days and its being extended because the nurses come to you/page you for problems instead of the person on call.
If you cannot turn your pager off, tell them when they call to "please page doctor x at #..., he is on call tonight." If they stop you in the hallway, ask if it is an emergency. If not, tell them to "please page doctor x at #...., he is on call tonight." You can even explain to them that because of the constant interruptions, you are violating the ACGME work hours because you are in the hospital for so long finishing work. If the program gets shut down, the nurses can expect to have to do all those things (phlebotomy, running labs, etc.) themselves. Say this nicely, without it being a threat. Pretty soon they will get the idea that they are expected to page the person on call, and not you if you are in the hospital late.
3) Consider coming in earlier. Most hospitals are quieter overnight. I'll bet if you came in at 5 instead of 6, you would see your patients faster and could get at least some of your notes written before rounds (see above). Once the day shift has come in, there will be lots of activity, people paging you, etc. Its not fun to come in that early, but I firmly believe you will go home earlier.
You have to do everything: talk/call patients' relatives, call PMDs to inform them their patients in some cases, obtain consent, phone call for specialty consult...
All of those things are standard at most teaching hospitals. In community hospitals nurses may get consent for procedures and may call consults, but in academics it is the resident's job to do these things. Frankly, you will be well advised if it is you calling the consult, instead of some ward clerk who knows nothing. There is little that infuriates a specialist than a consult from someone who knows *nothing* about the patient.
...Foley insertion, NG placement, check patients' status, give patient medications (some medications nurses refuse to inject so you have to do like metoprolol IV, Lasix IV).
Again, its probably New York and the nurses have figured out what they can get away with. I'm sure there is no rulebook which states that they don't do these things. IV Beta Blockade and other medications are commonly not given on regular floors without telemetry, so that's not suprising. And while I would like to have you tell the nurses to follow your orders, that it is their job to insert the Foleys, the NG, to give meds, etc. I'm sure this will backfire on you and you will end up worse off than you are now (ie, they will not only refuse to do these things but they will hate you and make your life miserable).
Is it possible to work as a team with some of your fellow interns and get some of these chores done faster? You help them with their patients, they help you. Or how about being more efficient and making a list of these things that need to be done and set aside a time when they will all happen (barring emergencies of course).
Since you mention that your fellow intern sometimes sleeps in the hospital to get things done, it might help if you and he/she could come up with a mutually satisfying solution. Maybe one day one of you stays late and does all these chores for both teams, and the other goes home early, and you trade off. Or you work like an assembly line:
- see who needs Foleys
- get all equipment together
- while one is inserting catheter, other is cleaning up after you, putting in order, etc.
My point being is that as a new intern, particularly one whom I assume has not worked in a US hospital before, you are probably very inefficient. Its ok, we all were. And you are facing some mighty obstacles which seem insurmountable. I have heard enough stories from my NY friends to know what you describe is true. But I also know that there is a lot of inefficiency built into medicine and your schedule as you describe it. There are solutions.
