programs with resident autonomy

[supercut]

I've posted some before about being unhappy with my current program. My discontent continues and I've spoken with my PD. I am now looking for a PGY 2 slot.

My primary source of discontentment stems from the fact that the residents have no autonomy here whatsoever. There is no rotation where the residents run things. The attendings stay firmly in control for every case, and continue to do so even now, even with chief residents who soon will be out their on their own. It is extrodinarily rare for a chief to take any junior resident through any case (teaching cases logged < 20)

This is a stark contrast to my medical school, where the residents frequently operated with minimal to no input from the attending. The PGY 4-5 routinely took PGY 1-2 through cases, and they log nearly 200 teaching cases.

So I'm looking for programs where the attendings actually let the chiefs do the operations. And one where chiefs do teaching cases regularly (I'd like to see a minimum of 80-100 teaching cases per chief)

I'm open to suggestions
Thanks

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[scutking]

Generally, any program with a large urban, county hospital will provide a resident with considerable autonomy. Some hospitals which come to mind are Charity (Tulane, LSU), Parkland (UTSW), Ben Taub (Baylor), Grady (Emory), Jackson (Miami), UT-Memphis, and LA County (USC).

 

[droliver]

Oversite @ even those programs you listed have been changing somewhat. The feds have shown a willingness to enforce fraud penalties for unsupervised care @ teaching hospitals & the effects have been filtering down since the late 1990's. Not signing an attestation sheet = not getting paid for federally (& even municalpally funded patients in some cases) funded patients. There are really no departments anymore that can afford to leave that money on the table. There was a huge change b/w the time I started in the late 1990's & finished in 2003. This includes the VA system where attending presence is even MORE closely scrutinized these days & you can be put in jail for it.


I still felt I had tremendous autonomy with my patients @ our University & VA hospitals, but the rules & standards have changed a lot. It's still hard to believe stories from the not too distant past you hear about.

 

[dr.evil]

I have to agree with dr.oliver. Resident autonomy is slowly becoming a thing of the past. Liability/lawyers/medicare run the medical world and they've really cracked down on this. Granted, county hospitals will continue to provide more autonomy that community hospitals on the whole. At my program we have enormous autonomy on the floors, ICU's, and doing simple procedures (lines, chest tubes, etc.) but the O.R. is becoming much more stringent. Just the way it is I guess. There is a happy medium between too much autonomy (i.e. without supervision on cases that need someone supervising) and staff scrubbed and "assisting" with every case.

 

[supercut]

So why are we so willing to accept that residents not being allowed to do any operations is "just the way it is"? How the heck are we supposed to learn to operate? Do we really want the first time we do an operation start to finish without an attending telling us what do to is after we get a job???

The balance is what's key...chiefs should be allowed to do basic operations without any attending input, but with the attending handy. THe attending should step on only if the chief asks for input OR if he/she sees the chief doing something wrong (and not just "wrong" because that's not how the attending does it)
Chiefs should also be allowed to do all the dissection for big cases (liver resection, whipple, etc) and then the attending should get involved only for the meat of the operation.

That's what I'm looking for. If I stay where I am, I won't be allowed to do that and the lack of skill I will have when I graduate scares the crap out of me.

 

[Winged Scapula]

I suppose it depends on how you define autonomy. As others have noted, Chief resident services where the Chief operates without an attending in...er, attendance, is increasingly becoming a thing of the past.

However, in my observation (at least here) Chiefs ARE doing the cases essentially from start to finish (with some exceptions of course). Is the attending in the room? Sure. Is the attending scrubbed? For most of the case. Is the attending "doing" the case? No. They may make some suggestions here and there but the Chiefs and more senior residents (and even the juniors on simpler cases) are doing the vast majority of the dissection, etc.

Of interest I was talking with one of our newer attendings who was relating the number of cases he's done as an attending that he'd never done or seen as a resident. Guess you gotta have a nice picture book for those!

 

[supercut]

So here's an example of why I am so unhappy.

One service I worked with an attending who was great. Very busy service, several times I was the only resident available to cover an add on case. So one time there was a pancreas debridement added on. I got to start it. The attending let me open the abdomen (many won't let interns...interns are retractor holders in that situation) and then we started by taking out the gallbladder. For that part, I was bovieing between the attendings clamp jaws, but since it was my first gall bladder, I thought that was pretty approprate. THe chief finished his other case and then came to do the pancreas part.

So a couple weeks later, there's another pancreas case and I didn't have a case, so I went to the OR with the chief. THe attending let us get started. The chief didn't let me do sqaut. The attending scrubbed in before time to even take out the gallbladder and instead of standing in the second assist spot and letting the cheif take me through the gallbladder, he bumped me down to second assist. THen he proceded to take the chief through the gall bladder. Fortunately, my pager started going crazy so I was able to scrub out instead of stand there like an idiot.

So later I asked the chief why I hadn't been allowed to take out the gall bladder. His response..."Oh, we forgot." I wanted to shout HOW COULD YOU FORGET since I was right there in front of them!!!!

On another service, I asked if the chief could take me through a hernia. THe response was absolutely not, if there is a recurrance it will get all over town. I was stunned.

 

[dr.evil]

That's definitely a rough experience but throughout the country you're lucky that you're in the OR as an intern. My experience has definitely been different. I did a colonoscopy on a patient early one morning and found a large rectosigmoid mass. Later that afternoon, the 4th year resident walked me through an LAR. The attending scrubbed after we got the exposure and stood between the patient's legs. His gloves never entered the abdomen. It was a great case and is exactly what I think surgical residency should be. At my institution though, it's very difficult to have two residents in the OR at the same time due to the sheer volume.

 

[njbmd]

Originally posted by supercut
So here's an example of why I am so unhappy.

One service I worked with an attending who was great. Very busy service, several times I was the only resident available to cover an add on case. So one time there was a pancreas debridement added on. I got to start it. The attending let me open the abdomen (many won't let interns...interns are retractor holders in that situation) and then we started by taking out the gallbladder. For that part, I was bovieing between the attendings clamp jaws, but since it was my first gall bladder, I thought that was pretty approprate. THe chief finished his other case and then came to do the pancreas part.

So a couple weeks later, there's another pancreas case and I didn't have a case, so I went to the OR with the chief. THe attending let us get started. The chief didn't let me do sqaut. The attending scrubbed in before time to even take out the gallbladder and instead of standing in the second assist spot and letting the cheif take me through the gallbladder, he bumped me down to second assist. THen he proceded to take the chief through the gall bladder. Fortunately, my pager started going crazy so I was able to scrub out instead of stand there like an idiot.

So later I asked the chief why I hadn't been allowed to take out the gall bladder. His response..."Oh, we forgot." I wanted to shout HOW COULD YOU FORGET since I was right there in front of them!!!!

On another service, I asked if the chief could take me through a hernia. THe response was absolutely not, if there is a recurrance it will get all over town. I was stunned.

Hey there,
Open choles are not that common these days with all of the lap surgery. Many of my chiefs would have taken out that gallbladder so don't take it personally. It would have been nice for the chief to let you remove the gallbladder but no obligation exists. I have been the starter in many big cases as a PGY-2, only to turn the case over to a chief. At my level, opening and closing properly is an absolute must and my attendings are very happy to start an advanced case with me. I happily scrub out when a senior resident appears to take the case. I have been able to complete some big cases but I wasn't "doing" the case. Most of the time, the senior resident will allow me to do some of the exposure with the attending. I chalk it all up to good experience for when I will be the senior resident later. I have never had a chief resident refuse to take me through a junior level case such as a hernia or even more advanced cases. That's a tough break for you.


A pancreas debridement is not a junior-level case. That attending is going to find a senior level resident or will do the case, period. As you gain more experience, you will quickly realize that standing across the operating table from an attending hitting the bovie now and again is not the same as "doing the case". I can't think of a single program in the country that is going to put a junior level resident into an inappropriate case where inexperienced operative technique can kill the patient. At your level, you still have plenty to learn about handling tissues and no attending wants to start out doing damage control. Observing the chief and the attending doing the case was the best place experience for you as a junior resident.

At my institution, the chiefs (4s and 5s) have plenty of autonomy but autonomy does not mean that you do cases independent of an attending. The chief may be the principle surgeon from start to finish but the attending has the final word and is responsible for the case. The chiefs experience little "interference" from the attending but they have the right to take over the case. I have never seen an instance where an attending took over a case from a chief.

I vividly remember a graduate of our program relating how different it was to be an attending and doing cases independently in private practice. He said that it's totally different from when you had the back-up of that attending even as a chief. He said that if you are lucky, you start to hear your best attendings whispering in your ear as you go through a complicated case by yourself.

njbmd

 

[Talula]

It sounds like you liked your medical school's program - why didn't you stay there?

 

[supercut]

Yikes! I ask for some advice and do some venting.... Please be advised that I am FULLY aware that a pancreas case in not a junior level case. HOWEVER, when the same attending who previously was happy to let me open and take out the gallbladder didn't make sure that happened on a second case later in the same rotaion, I was put off. Especially in light of how little the interns learn. I've gotten so little out of this year that I feel like my knowlege and skills are regressing, rather than progressing. I'd be delighted if I was getting to open and close the abdomen. But it's only happened twice.

As for why I'm not at my med schools programs, the reasons are multiple...family issues, malignancy issues.... besides my class had almost 3 times as many people go into gen surg and my schools programs has slots. No way could they accomodate everyone who wanted to stay. Besides, the match process doesn't allow you to merely pick a program.

BTW, NJBMD...I saw you posted on the program directors web site looking for a PGY 3 slot. How's that going? Do you think posting there is helpful? I'm debating about doing that myself.

 

[FliteSurgn]

Our residency is affiliated with a county hospital. We get a ton of autonomy there. There's a third-year and a chief rotating there at all times. Depending on the chief's preference and comfort, the third-year gets to do a large variety of cases.

Today, we did a laparoscopic bilateral groin hernia repair. I did one side after I talked the junior through the other. Then I watched over his shoulder as he did a lap appy. I let the juniors do all of the gallbladders with or without me scrubbed. The juniors do open hernias with just a med student assisting once I'm comfortable with their ability. We always have staff "available", but we get to run the show in the OR. It's awesome.

I have about 100 cases as teaching assistant. I've given up lots of cases to the junior residents beginning my third-year. I already felt so comfortable with the basic laparoscopy and stuff that I would rather the 1st and second years get a piece of the action. Ah, community programs are great.

 

[njbmd]

BTW, NJBMD...I saw you posted on the program directors web site looking for a PGY 3 slot. How's that going? Do you think posting there is helpful? I'm debating about doing that myself. [/B][/QUOTE]

Hi there,
Very helpful! I have one!
njbmd