PGY-2 Year Advice?

[TUGM]

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Welp... about to start my time as a two-tern. Any last minute advice from the not-so-newbies for how to make it at a big academic program?

I'm starting on NSICU. Yikes, but also 🙂.

 

[typhoonegator]

The more organized you are, the more time you will have to learn, both in didactics and on-the-fly.

For NSICU, depending on if the unit is open or closed, individual attending preferences for post-op care and SAH management can be widely disparate -- learning what each one likes (regardless of what the textbook says you should do) will make your time easier. Too bad you'll be starting so early in the year there -- less chance of getting to place bolts and drains because the neurosurgeons will be jockeying for them.

 

[deathmerchant]

Agree with the above advice. I don't know why, but in Neuro there is a lot of individual attending preference: the sooner u learn that, the easier ur life will be. May be we dont have slam dunk evidence for a lot of clinical scenarios and tbh there is a lot of variability in disease presentation and course and response to management.

 

[doublebuckeye]

My advice is to absorb as much as you can and keep your ears and mind open. You're not going to have much time to read if you have a front-loaded program like most. Try to read about a condition you managed that day that you don't know much about each night. Shouldn't take you too long.

 

[NeuroAP86]

I am struggling with pgy2 year so far. We do overnight call and I've done 3 already with no recollection of how or why I did things. It seems more survival at night. Biggest thing that worries me is what was said above about attending preference. I've heard from seniors at my program that at our primary rotation site (inpatient academic center) that the attendings are not very good at teaching and you have to learn on your own. That's fine with me but being pgy2 year I don't see a lot of time available to read. The other two sites (va and large community hospital) have much better attendings so I guess that makes up for it but this def worries me going forward about how much I will be able to learn and be taught.

 

[typhoonegator]

First off, update your status if you're not a medical student.

Second, night time at busy hospitals are not typically the best time to kick back with Bradley and Daroff. Learn about each case as you go if you can, and I always found overnight admissions to be the most educational because you could see how the day team modified your initial plan the following morning. Not all attendings are created equal, but there are many who feel too busy or pressured to devote dedicated time to teaching didactically or on rounds -- some even have bad memories of attendings that dragged things out and kept the residents from getting their work done. Many just want to get through the day, particularly if they are academic as they have another life waiting for them back in the lab. That's not an excuse, however, at an academic center, but it is how things are. A lot of them will engage if you ask them specific questions about patients and their decision making.

People learn in different ways. I was never a big book reader. Too boring. But I came up with questions during each admission and during rounds, and could look stuff up when I had time. Remember that you've been doing this for 2 weeks. As you build efficiency and get better at pattern recognition, things will open up for you and you'll have more time for investigation.

 

[NeuroAP86]

Thanks for the response and I will change it to resident. I am just feeling overwhelmed and transitioning from medicine is becoming more difficult than I thought. I just fear that I am not enjoying this and actually disliking it. I'm starting to think neurology may not be what I wanted to do to begin with and now that I'm in it fully, it's becoming very evident. As a student I was excited to learn about it but this isn't the case right now. Hope I am wrong and it gets more enjoyable over time.

 

[typhoonegator]

Give it some time, chief. You won't always be the least experienced person in the room. Nothing is fun when you have all this responsibility without knowledge or authority. It's still July.

 

[NeuroAP86]

Thanks. I'm going to try to stay positive about it and keep pushing along. If in a couple months I'm still feeling this way, then at least I know I gave it a shot.

 

[TUGM]

apevo8, hang in there. I felt like a decapitated chicken for my first few calls in a 24-bed neurology/neurosurgery ICU, but it definitely gets better as you progress through. You spent your first year doing medicine, and neurology is a different beast, with new protocols and pathophysiology. On call, I tried to learn one small thing from each patient - indications for hypertonic saline, complications of mannitol, ASIA criteria, ICH scoring, etc. This way I was able to get a bit of exposure to different things, and tried to apply that knowledge directly to the next patient that presented with a similar issue.

Also, we as PGY-2s are only one month in! I felt like I had made a horrible mistake choosing neurology, but it was only because I was so stressed. Once I dispelled some of that initial anxiety, I find the subject matter so exciting and interesting again!

*edited for post-call grammatical errors*

 

[barzan]

Nice description of your experience hope you continue writing here about it. I am currently doing my internship and can't wait for PGY2 to start.

 

[thepretender67]

Can people talk about what the responsibilities generally are for PGY-2 Neurology Intern? For example during my prelim program- I mainly make sure that H/Ps, Progress notes are written, Discharge orders and Dictations are done, I call consults, social work etc.

Do neurology interns do a lot of the scut work as you do in prelim year or do you still have a lot of responsibility to make your own management decisions for patients?

 

[kchan99]

Can people talk about what the responsibilities generally are for PGY-2 Neurology Intern? For example during my prelim program- I mainly make sure that H/Ps, Progress notes are written, Discharge orders and Dictations are done, I call consults, social work etc.

Do neurology interns do a lot of the scut work as you do in prelim year or do you still have a lot of responsibility to make your own management decisions for patients?

Scut work tends to be hospital-dependent. For example, in some hospitals, you will have to put in all small bore feeding tubes but in other hospitals, nursing may be permitted to place them. I would expect that you would be independent in making decisions in management of internal medicine issues, but responsibilities in management of neuro issues will increase as you progress through the year. In my program, junior residents were "acting seniors" while on night float in their third month of stroke and general neurology.

Reading during a busy ward month is difficult, but I tried to read one paper on each interesting patient. I also looked in Uptodate, but I don't consider that to be real reading. You will never read enough. There is always more to read. In the beginning, reading can be daunting. Sometimes, you might not know where to start. My advise is to read something. I remember seeing a patient with inflammatory CAA for the first time. If I remember correctly, I started with a review article or imaging. The next time I read pathology. Then I read about treatment.

 

[LuccaDO]

Scut work tends to be hospital-dependent. For example, in some hospitals, you will have to put in all small bore feeding tubes but in other hospitals, nursing may be permitted to place them. I would expect that you would be independent in making decisions in management of internal medicine issues, but responsibilities in management of neuro issues will increase as you progress through the year. In my program, junior residents were "acting seniors" while on night float in their third month of stroke and general neurology.

Reading during a busy ward month is difficult, but I tried to read one paper on each interesting patient. I also looked in Uptodate, but I don't consider that to be real reading. You will never read enough. There is always more to read. In the beginning, reading can be daunting. Sometimes, you might not know where to start. My advise is to read something. I remember seeing a patient with inflammatory CAA for the first time. If I remember correctly, I started with a review article or imaging. The next time I read pathology. Then I read about treatment.

Can you please elaborate on what resources you used for reading? Current OMS-IV applying exclusively neuro trying to get a head start on a good reference/learning system before residency begins. I have found that Summary/Recommendations of UpToDate is really valuable, but reading about all of the small cited studies in the body of the reading is really not time efficient.. Furthermore, UpToDate provides little review of pathophysiology and neuroanatomy. Are there any reference materials out there that tie in these subjects/a good basic science review?

 

[kchan99]

I didn't start reading neuro until the end of my PGY-1 year. In my opinion, it is easier to remember reading material in neuro once you have more exposure to neuro patients. I never set up a reading system. Once I started seeing patients and reading, in anything related to neurology patients, I realized my weaknesses. You will take RITE in PGY-2 through PGY-4, but unlike my co-residents, I never purposefully studied for these exams.

In MS-IV, I continued to focus on the basics, mainly internal medicine, to prepare for PGY-1 since I was treated as a medicine resident during PGY-1. However, I did rotation-specific reading. I spent half of my MS-IV year in rotations not related to neurology because I wanted to have exposure to areas of medicine that I would not see again. My non-neuro rotations were in dermatology, ophthalmology, forensic pathology, and nephrology along with medicine AI. In dermatology, I read about rashes, but I also read about phakomatoses, such as tuberous sclerosis and neurofibromatosis.

For reviewing neuroscience, I kept Rapid Review Neuroscience and a neuroanatomy text. I also have a couple of neuroanatomy atlases, including Haines and Jennes. Also review anatomy, not just neuroanatomy. Gross anatomy knowledge is helpful for EMG. Hint: Keep your Netter and Rohen atlases.

 

[thepretender67]

Can you tell me about what your responsibilities were as a PGY-2? When you say Jr resident, you mean PGY-3?

 

[kchan99]

Can you tell me about what your responsibilities were as a PGY-2? When you say Jr resident, you mean PGY-3?

PGY-2 = junior resident
PGY-3 & 4 = senior resident
Junior resident duties while on ward service: admissions, discharges, call consults, progress notes, orders, procedures like LPs, etc. So PGY-2 in neuro is being an intern again.

 

[thepretender67]

I know different attendings like to hear different things, and these are probably difficult questions to answer, but would like to get some feedback. Any tips on how to stay organized with patients that are very complicated that have many different problems? Any tips on presenting patients in neurology (any notable differences vs IM)?

 

[typhoonegator]

Plans by system, with problems listed according to the primary originating system, with diagnostic, therapeutic, and prognostic concerns for each neuro problem. Bonus points if the problems are in the form of an ICD10 code. For a problem like aSAH, list pending problems along with actual issues within that problem, like monitoring for hydrocephalus, monitoring for vasospasm, monitoring for DCI, monitoring for CSW, etc. even if they aren't currently present. This was a big change for me because I came from a medicine prelim where the de rigeur was plan by problem/diagnosis, so something like respiratory failure could have multiple organ systems involved in the discussion.

Or, you know, just ask the rising PGY-3's how they organized their notes and presentations, and just do that.

 

[thepretender67]

How can I prepare to survive my rotations in the neuro-icu?

 

[TUGM]

Show up early so you have plenty of time to collect information. Be meticulous, know vitals from overnight, labs and their trends, Is/Os, ventilator settings, and medications on your patients. Do thorough exams on patients. Know the patient's code status and proxies. Maintain a good rep with family members so that they will trust you when the time comes to make difficult medical/ethical decisions. Earn the trust of your nursing staff as well - they will likely know more than you when you first start out, so respect their input - they will in turn, make your life easier.

Learn common procedures: indications, complications, technique. Central venous catheters (especially subclavian and femoral), arterial line insertion, lumbar punctures should be your priorities to learn. Eventually, if you have some helpful NSGY residents or attending, EVDs.

Learn your pressors and their indications.

Read. Read. Read. Including the guidelines.

Hold on to your butts.

The best advice I ever got: "You'll be alright."

 

[kchan99]

Show up early so you have plenty of time to collect information. Be meticulous, know vitals from overnight, labs and their trends, Is/Os, ventilator settings, and medications on your patients. Do thorough exams on patients. Know the patient's code status and proxies. Maintain a good rep with family members so that they will trust you when the time comes to make difficult medical/ethical decisions. Earn the trust of your nursing staff as well - they will likely know more than you when you first start out, so respect their input - they will in turn, make your life easier.

Learn common procedures: indications, complications, technique. Central venous catheters (especially subclavian and femoral), arterial line insertion, lumbar punctures should be your priorities to learn. Eventually, if you have some helpful NSGY residents or attending, EVDs.

Learn your pressors and their indications.

Read. Read. Read. Including the guidelines.

Hold on to your butts.

The best advice I ever got: "You'll be alright."

In my experience, procedures are program-dependent. I'm not talking about lumbar punctures. I'm talking about central lines. In my program, we had to take a ultrasound guided class, and then priority was given to residents who were interested in neurocritical care.

 

[typhoonegator]

Resident survival in the neuroICU is about 1) knowing your limits, 2) asking for help from literally everyone around you, 3) being visible and accessible to the nurses throughout the day, 4) knowing and building relationships with the families, 5) keeping up to date with everything going on with your patients, 6) maintain constant clinical awareness of how the things you are doing or not doing could end the life of your critically ill patient, and 7) doing absolutely everything possible to align yourself with the nurses

ICU nurses are a very different sort of people than ward nurses. In many ICUs, they share a peer relationship with the fellows and attendings because they are trusted and incredibly skilled partners in patient care. They see themselves rightfully as the final safety check before any plan is implemented on their patient, and because they are standing at the bedside or within view of their patient for their entire shift, they are very connected with what is going on. That's not to say they are infallible or that it's appropriate for them to dictate care plans, but in all things you must strive to build consensus. Treat them as someone you can learn a lot from, because it's true. Treat them as a partner in the therapeutic alliance, because the two of you are far more effective together than either are alone, and because they were there before you strolled in, and will be there after you stroll out. Ask them what THEY think is going on. They can sniff out laziness and airs of superiority a mile away, and you can get labeled really quickly which can make your rotation much more challenging than it needs to be. If your goal is to serve as a useful cog in the ICU machine and learn as much as you can, then you'll do fine. If you goal is to show everyone how smart you are and teach the nurses a thing or two about volume status, you are in for a world of hurt.

Other than that, round with the team, and then round again and again all day long. Did the echo team come by after rounds? You should know the answer. Did they pee out to that Lasix? You should know the answer. Did the guardianship paperwork get filed? No, but the sister is flying in from Montana tomorrow. Nice! You're on your way.

Finally, try not to make eye contact with your attending. Look above their head and slightly to the side while speaking to them in short declarative sentences. They may see eye contact as a challenge to their alpha status and seek satisfaction through pistols at dawn. If this occurs, roll over and expose your soft underbelly as a demonstration of your subservience to their will. This will usually lead to diversion of their bloodlust, and a jubilant round of fist bumps for all (except the pharmacist who has been pretty slow lately with the trough-adjusted vancomycin dosing and must be publicly shamed).

 

[bustbones26]

Now, don't forget about the RITE exam during your PGY-2 year. Study for the damn thing at every given opportunity. Ask your advisor, mentor, senior residents, program administrator, anybody in general, if they have copies of the old RITE manuals for you to study. You will be at a disadvantage as most programs have little (if any) didactic exposure to clinical neurophysiology, child neurology, or neuropathology, during your PGY-2 year. Unfortunately, those are major portions of the exam so start hitting it now!!

Matters not if you rock the neuroICU, master the neuro exam blindfolded, or learn how to use a maddox rod on every diplopia patient. Let's be honest and blunt here, you screw up the RITE, you're attendings will not give you the time of day or any opportunities.

No pressure, just reminding you that some time per week should be carved out for studying for the RITE before the Spring sneaks up on you.

 

[TUGM]

I definitely agree that studying for RITE at some point is important. In my experience, the PDs will care the most about your RITE exam score, at least as a PGY-2. Most of my attendings think the exam is a joke, and most recommended bombing the first one and enjoying a semi-day off - that way, you are almost guaranteed to show improvement from exam to exam.

Just study a bit every night, and read things you find interesting within the realm of neurology. Show up for work, and work hard. Get your hands dirty at every opportunity and I think you'll turn out okay.