Psychiatry intern on medicine...please help?

[HemeOncHopeful19]

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Where I trained the off-service Psych interns just did one month of medicine! WTF!?

 

[PS2summerdays]

Where I trained the off-service Psych interns just did one month of medicine! WTF!?

That’s more than enough lol.

 

[PS2summerdays]

2.5 more weeks to go...at my breaking point now lol. Anyone feel like the hospitals have been especially busy recently?

 

[Chads2]

OP,

First of all, I wish I had gotten to this thread sooner. I’m an IM teaching attending and at this point in my career, I’ve had many, many off-service interns. Yes, I believe it’s inhumane for you to be on wards for so long. You must be in a program where the residents are not plentiful in number and psych residents are expected to be all-purpose interns.

As an attending, my expectation is always that the off-service intern knows quite a bit less medicine and I am training them to keep patients alive this year and then in the upcoming years to recognize when you need an internist’s help. (“That’s not dementia, that’s crypto meningoencephalitis!”)

I almost never expect an intern to know everything...at least the first time around. If on day one, I ask you “what’s the INR today?” I don’t expect you to have it stored in your head. I expect you to look it up and give me the answer faster than I can click on it myself. But I also expect you to have that number ready on day 2 and every subsequent day be cause I asked for it.

like I said, I wish I’d been on this thread sooner but you’re almost done. Just keep swimming.

 

[PS2summerdays]

OP,

First of all, I wish I had gotten to this thread sooner. I’m an IM teaching attending and at this point in my career, I’ve had many, many off-service interns. Yes, I believe it’s inhumane for you to be on wards for so long. You must be in a program where the residents are not plentiful in number and psych residents are expected to be all-purpose interns.

As an attending, my expectation is always that the off-service intern knows quite a bit less medicine and I am training them to keep patients alive this year and then in the upcoming years to recognize when you need an internist’s help. (“That’s not dementia, that’s crypto meningoencephalitis!”)

I almost never expect an intern to know everything...at least the first time around. If on day one, I ask you “what’s the INR today?” I don’t expect you to have it stored in your head. I expect you to look it up and give me the answer faster than I can click on it myself. But I also expect you to have that number ready on day 2 and every subsequent day be cause I asked for it.

like I said, I wish I’d been on this thread sooner but you’re almost done. Just keep swimming.

Wish more attendings were like you. Thanks for the insight. Less than a week left now. Feel numb everywhere mentally and physically lol. Gained a bunch of weight and developed bad habits over the past several months. I dunno how you IM people do it without breaking. Though, I will say, not even the IM interns do floors consecutively for this many months.

 

[robellis]

Wish more attendings were like you. Thanks for the insight. Less than a week left now. Feel numb everywhere mentally and physically lol. Gained a bunch of weight and developed bad habits over the past several months. I dunno how you IM people do it without breaking. Though, I will say, not even the IM interns do floors consecutively for this many months.

Surgery is a lot lot worse than IM months and they do it for years, you will get through it and it’ll toughen you up a bit

 

[Mad Jack]

Lol let’s not take it that far..you’re practicing medicine you’re not a slave in the fields..not that big of a deal man just keep going you’re almost done

Cognitive demands can be much more distressing than mindless physical ones. There's also a big difference between doing something for 80 hours a week for several months that you want to do for the rest of your life and something you're forced to do that you'd rather not be doing. Drafted soldiers and conscripts tend to not fare as well as volunteers, and so it goes for medicine.

If you tried to force most non-physicians to do medicine (medical school, wards, any of it), they would become depressed, guaranteed. It's a challenging lifestyle and most would be content to do almost anything else.

 

[robellis]

Cognitive demands can be much more distressing than mindless physical ones. There's also a big difference between doing something for 80 hours a week for several months that you want to do for the rest of your life and something you're forced to do that you'd rather not be doing. Drafted soldiers and conscripts tend to not fare as well as volunteers, and so it goes for medicine.

If you tried to force most non-physicians to do medicine (medical school, wards, any of it), they would become depressed, guaranteed. It's a challenging lifestyle and most would be content to do almost anything else.

Well agree to disagree, IM is the core of all medicine, it’s the quintessential “doctor” if you can’t manage a few months of it during residency maybe being a doctor isn’t for everyone. Surgery is a different beast and certainly not everyone should be forced to do months of that

 

[Chads2]

I dunno how you IM people do it without breaking.

Because we love it. You put me on psych for a few months and I would be just as broken down as you.

Polish off your DSM-V. It’s waiting for you.

 

[Mad Jack]

Well agree to disagree, IM is the core of all medicine, it’s the quintessential “doctor” if you can’t manage a few months of it during residency maybe being a doctor isn’t for everyone. Surgery is a different beast and certainly not everyone should be forced to do months of that

I mean surviving it is one thing, but I wouldn't expect someone that isn't going into IM or an IM subspecialty to not be mildly to moderately depressed on the inpatient service. I thought it was fine, but I can definitely see it making some people miserable

 

[mvenus929]

Well agree to disagree, IM is the core of all medicine, it’s the quintessential “doctor” if you can’t manage a few months of it during residency maybe being a doctor isn’t for everyone. Surgery is a different beast and certainly not everyone should be forced to do months of that

I mean, I'm pretty sure attending IM docs aren't doing 60-80 hours of wards per week, every week, for months on end... And those in IM programs may have a couple months in a row that they do that, but it's sprinkled with outpatient or other lighter rotations where you can reclaim some of your sanity.

At least, that's how it is in peds. Maybe IM people are just bred differently.

 

[PS2summerdays]

I mean, I'm pretty sure attending IM docs aren't doing 60-80 hours of wards per week, every week, for months on end... And those in IM programs may have a couple months in a row that they do that, but it's sprinkled with outpatient or other lighter rotations where you can reclaim some of your sanity.

At least, that's how it is in peds. Maybe IM people are just bred differently.

Yeah all the main IM people or pre lims have at most 4 weeks in a row on floors. Otherwise it’s usually 3 weeks floors 1 week outpatient or 2 weeks floors 2 weeks elective.

 

[Chads2]

Congratulations on surviving!

 

[deleted1022040]

Yeah all the main IM people or pre lims have at most 4 weeks in a row on floors. Otherwise it’s usually 3 weeks floors 1 week outpatient or 2 weeks floors 2 weeks elective.

How are things since you survived IM?

By the way, damn proud of you not only for opening up about what you were feeling/experiencing but for pushing through.

 

[PS2summerdays]

Guess I'll update this. I survived. Am attending now and enjoying the California sun. Life is good.

 

[dozitgetchahi]

Guess I'll update this. I survived. Am attending now and enjoying the California sun. Life is good.

Good to hear.

Btw, as an IM intern I once did 5 consecutive rotations of wards and night float (only one of those was night float), and later as a PGY-3 I did yet another 5 consecutive rotations of ICU and wards (q4 call). And yes, it was ****ing brutal. I remember coming off that first 5 month block as an intern and feeling just…crispy fried. It took almost an entire month to feel normal again.

 

[LucidSplash]

Good to hear.

Btw, as an IM intern I once did 5 consecutive rotations of wards and night float (only one of those was night float), and later as a PGY-3 I did yet another 5 consecutive rotations of ICU and wards (q4 call). And yes, it was ****ing brutal. I remember coming off that first 5 month block as an intern and feeling just…crispy fried. It took almost an entire month to feel normal again.

<Chuckles in surgeon>

 

[dozitgetchahi]

<Chuckles in surgeon>

And that’s why I’d rather be dead than be a surgeon. I work bankers hours as a rheumatologist and couldn’t be happier.

One thing the millenials/gen Z got right was the emphasis on lifestyle (even if there are a lot of other aspects of the millennial generation that make me embarrassed to be a part of it sometimes). And I like that medicine is starting to go that way.

 

[LucidSplash]

And that’s why I’d rather be dead than be a surgeon. I work bankers hours as a rheumatologist and couldn’t be happier.

One thing the millenials/gen Z got right was the emphasis on lifestyle (even if there are a lot of other aspects of the millennial generation that make me embarrassed to be a part of it sometimes). And I like that medicine is starting to go that way.

Oh I have a great lifestyle now that I love. I should have said <chuckles in surgery resident>.

Surgeons will work more than a lot of their IM or IM-fellowship counterparts but there are more surgicalist and other non-traditional setups available now too. And for the more traditional setups it depends on your call schedule. I’m about to take a job with 1 in 4 call, which is fine by me. Reasonable lifestyle and I get to operate.

I wasn’t maligning your choices to be clear. Just your comment made me think back to residency. I wouldn’t change my residency either, as I think I was exceedingly well trained in Gen Surg at a time when not all Gen Surg training is like that anymore. I hear horror stories, for example, about people in other programs going on to do bariatrics fellowships and their program needing to take the first 6 months to teach them to take out a gallbladder because they never really got to drive the bus as a resident. I don’t think that’s the norm everywhere, but I am hearing more and more stories like this, where people do fellowships because they don’t feel confident or competent to do gen surg. There are lots of reasons to do a fellowship, but that shouldn’t be one of them IMHO.

I’m thankful that I graduated Gen Surg ready to be a general surgeon, even if I don’t practice that anymore, but there’s a lot of value in how I was taught to think and operate. I’m of the school where I am willing to sacrifice more of my “lifestyle” during training to be well trained and focus on lifestyle after training. For surgery, I think the only way to have better “lifestyle” in training would be to extend the length of training and I wouldn’t prefer that approach. And we tried nightfloat at my program when the 16-hour thing came around for interns and it was universally hated. So they went back to traditional call as soon as that rule lapsed.

But then again, I’m classified as an “elder millennial” or a Xennial. So maybe that’s part of my viewpoint.

 

[FlowRate]

I wasn’t maligning your choices to be clear. Just your comment made me think back to residency. I wouldn’t change my residency either, as I think I was exceedingly well trained in Gen Surg at a time when not all Gen Surg training is like that anymore. I hear horror stories, for example, about people in other programs going on to do bariatrics fellowships and their program needing to take the first 6 months to teach them to take out a gallbladder because they never really got to drive the bus as a resident. I don’t think that’s the norm everywhere, but I am hearing more and more stories like this, where people do fellowships because they don’t feel confident or competent to do gen surg. There are lots of reasons to do a fellowship, but that shouldn’t be one of them IMHO.

Genuinely curious--does one really need to be in the hospital an ungodly number of hours to actually get more hours in the OR or is this a "paying your dues" thing where the residents are taking care of the rest of the service 50%+ of the time and thus in the OR less because of other responsibilities? Then, when duty hours are limited, that 50% OR time is probably the first thing to go in favor of making everything else run smoothly, while the attendings continue to operate.

 

[LucidSplash]

Genuinely curious--does one really need to be in the hospital an ungodly number of hours to actually get more hours in the OR or is this a "paying your dues" thing where the residents are taking care of the rest of the service 50%+ of the time and thus in the OR less because of other responsibilities? Then, when duty hours are limited, that 50% OR time is probably the first thing to go in favor of making everything else run smoothly, while the attendings continue to operate.

Surgery is so so so much more than being in the OR. Far more complications occur because of mistakes in preop and postop care than in intraop settings. The gestalt of when to operate and when something is “wrong” with a preop or postop patient only comes with thousands of hours of patient care. That being said, what you learn by doing the same procedures over and over again is a) what to do when plan A, B, or C fails in the OR b) what to do when the case is complex/not straight forward, c) how to stay as safe as possible for the patient when the case isn’t straight forward. There is a big difference in taking out a gallbladder for biliary dyskinesia vs the gallbladder for acute on chronic cholecystitis that the patient waited way too long to come in for. In addition, you have to consider that surgical emergencies happen and someone has to be there to do them. But you don’t know when they will come, but someone has to be there to recognize them and to take care of them. We could probably save a lot of in-house on call hours if we had a crystal ball to let us know when they’d come in, but we don’t. Likewise, while many of the basic principles are the same for an elective case vs an emergent one, any surgeon can tell you they are wholly different beasts. For example, an elective hemicolectomy for a small tumor is different than one for perforated diverticulitis. And how do you decide if you need to do the urgent hemicolectomy or if the patient might do ok with a drain for now or a laparoscopic washout instead and then plan a hemicolectomy a few weeks down the road when the inflammation has died down and the patient is less likely to have a complication? Or that taking out a colon for toxic megacolon is way different than these situations, even though to a non-surgeon they all are just variations on a colectomy.

Further, you spend more hours as a young surgery resident learning the pre/postop care and more time later operating. I took home call most of my chief year, like most of my attendings outside trauma. Like I do now. There is also skill in learning how to assess if you need to come in and see the patient vs tucking them in overnight and seeing them in the morning. As a younger resident you need to see/lay hands on as many patients as possible to start to develop the kind of knowledge that eventually lets you develop that sixth sense.

At my program, interns were in the OR a fair bit. Occasionally as the only resident, but most often assisting the attending and a more senior resident. But those opportunities as an intern or junior resident to do a gallbladder skin to skin with the attending essentially disappeared with night float, as did other opportunities to do cases, as there really is quite a lot that doesn’t get done in the middle of the night. I would assess that most people at my program felt comfortable with a basic lap gallbladder by the end of PGY 3. But definitely still needed additional training time to safely tackle a terrible acute on chronic cholecystitis that had been smoldering awhile, on their own. I almost missed a diagnosis of early acute cholangitis over the phone as a chief, but something about the ED residents and surgery resident’s assessment of acute cholecystitis didn’t sound quite right and I eventually decided to come in and see the patient myself.

So I don’t think it’s just hazing or “paying dues.” I think those clinical hours are meaningful in developing the surgical mindset.

I’ve said on this board before that I believe there is something different about surgical training that often makes a surgeon better than many other specialties at assessing “sick vs not sick.” I think this trait is often shared by non-surgical specialties like ED or PCC too of course. I think it has to do with the need to make big decisions with compressed timelines. I value my non-surgical colleagues greatly, but can count any number of times where medical management has been attempted for too long before a surgeon is consulted and then the surgeon immediately recognizes a surgical emergency. Again I am not denigrating my colleagues here, they aren’t trained to recognize this the way surgeons are. Not all surgical emergencies are obvious. I have seen closed loop bowel obstructions, infected necrotizing pancreatitis, and even cold legs misdiagnosed, delayed diagnosis, or missed entirely. Likewise, I’m not the best person to manage someone’s hyperglycemia or chronic hypertension, for example. It wasn’t the focus of my training. We all need each other.

 

[FlowRate]

Surgery is so so so much more than being in the OR. Far more complications occur because of mistakes in preop and postop care than in intraop settings. The gestalt of when to operate and when something is “wrong” with a preop or postop patient only comes with thousands of hours of patient care. That being said, what you learn by doing the same procedures over and over again is a) what to do when plan A, B, or C fails in the OR b) what to do when the case is complex/not straight forward, c) how to stay as safe as possible for the patient when the case isn’t straight forward. There is a big difference in taking out a gallbladder for biliary dyskinesia vs the gallbladder for acute on chronic cholecystitis that the patient waited way too long to come in for. In addition, you have to consider that surgical emergencies happen and someone has to be there to do them. But you don’t know when they will come, but someone has to be there to recognize them and to take care of them. We could probably save a lot of in-house on call hours if we had a crystal ball to let us know when they’d come in, but we don’t. Likewise, while many of the basic principles are the same for an elective case vs an emergent one, any surgeon can tell you they are wholly different beasts. For example, an elective hemicolectomy for a small tumor is different than one for perforated diverticulitis. And how do you decide if you need to do the urgent hemicolectomy or if the patient might do ok with a drain for now or a laparoscopic washout instead and then plan a hemicolectomy a few weeks down the road when the inflammation has died down and the patient is less likely to have a complication? Or that taking out a colon for toxic megacolon is way different than these situations, even though to a non-surgeon they all are just variations on a colectomy.

Further, you spend more hours as a young surgery resident learning the pre/postop care and more time later operating. I took home call most of my chief year, like most of my attendings outside trauma. Like I do now. There is also skill in learning how to assess if you need to come in and see the patient vs tucking them in overnight and seeing them in the morning. As a younger resident you need to see/lay hands on as many patients as possible to start to develop the kind of knowledge that eventually lets you develop that sixth sense.

At my program, interns were in the OR a fair bit. Occasionally as the only resident, but most often assisting the attending and a more senior resident. But those opportunities as an intern or junior resident to do a gallbladder skin to skin with the attending essentially disappeared with night float, as did other opportunities to do cases, as there really is quite a lot that doesn’t get done in the middle of the night. I would assess that most people at my program felt comfortable with a basic lap gallbladder by the end of PGY 3. But definitely still needed additional training time to safely tackle a terrible acute on chronic cholecystitis that had been smoldering awhile, on their own. I almost missed a diagnosis of early acute cholangitis over the phone as a chief, but something about the ED residents and surgery resident’s assessment of acute cholecystitis didn’t sound quite right and I eventually decided to come in and see the patient myself.

So I don’t think it’s just hazing or “paying dues.” I think those clinical hours are meaningful in developing the surgical mindset.

I’ve said on this board before that I believe there is something different about surgical training that often makes a surgeon better than many other specialties at assessing “sick vs not sick.” I think this trait is often shared by non-surgical specialties like ED or PCC too of course. I think it has to do with the need to make big decisions with compressed timelines. I value my non-surgical colleagues greatly, but can count any number of times where medical management has been attempted for too long before a surgeon is consulted and then the surgeon immediately recognizes a surgical emergency. Again I am not denigrating my colleagues here, they aren’t trained to recognize this the way surgeons are. Not all surgical emergencies are obvious. I have seen closed loop bowel obstructions, infected necrotizing pancreatitis, and even cold legs misdiagnosed, delayed diagnosis, or missed entirely. Likewise, I’m not the best person to manage someone’s hyperglycemia or chronic hypertension, for example. It wasn’t the focus of my training. We all need each other.

Interesting, my thought process with my question was context of your comment about people doing fellowship due to lack of confidence with what sounded like relatively B&B procedures, which I usually hear attributed to less OR time. But is it actually this lack of training exposure overall? (I was probably incorrectly assuming that residents end up still getting a lot of the out-of-OR experience that you're referencing with your reply.) Sounds like it's really missing out on the whole experience with less duty hours.

 

[LucidSplash]

Interesting, my thought process with my question was context of your comment about people doing fellowship due to lack of confidence with what sounded like relatively B&B procedures, which I usually hear attributed to less OR time. But is it actually this lack of training exposure overall? (I was probably incorrectly assuming that residents end up still getting a lot of the out-of-OR experience that you're referencing with your reply.) Sounds like it's really missing out on the whole experience with less duty hours.

I think it’s due to not getting to drive the bus. You can be in the OR, but if you’re not getting to do the case in appropriate graduated autonomy, you won’t have the confidence or experience at the end of your formal training. And for most, you have to physically do it. You can feel like you know how to do it if you watch a bunch of the same case. But it’s different when you’re making the decisions, you aren’t being constantly told or prompted what the next step is, or what to do if something goes a little awry.

My program had and has a chief service, which I think is key. The majority of the bread and butter cases are done with the chief doing the case and/or taking a junior or midlevel resident through the case and the attending sitting in the lounge, on call if needed. Bigger cases the attending might still scrub (wipple, etc) for key portions. I remember doing an exlap in the middle of the night as the chief for a toxic megacolon. Think like huge anaconda ready to pop necrotic balloon of nastiness. I was about halfway through, doing with the midlevel/senior res on call with me and just felt like I was taking too long and stressed for the patient so I called the attending in from the lounge. He came in, looked over my shoulder, said something like “mmhmm, mmhmm, mmhmm, that’s a terrible colon. Keep going.” And then left again. Later he told me it was a tough case and he felt I was doing fine and just needed to know that and finish it myself. Which I did and the patient did fine. But he’d operated with me for 5 years at that point so he knew what I was capable of and letting me finish the case on my own was what I needed.

That’s what I mean by driving the bus. With training wheels of course. But if he had done the whole case with me assisting in the middle of the night, or had assisted me but guided me by holding out the right tissue planes at the right time etc, I wouldn’t have gotten the same experience out of it. Or if there’s always a fellow or a superfellow in the case, or if you don’t get enough operative experience before you get to the chief level and the attendings don’t feel comfortable letting you drive the bus. Or if it’s the kind of place where they don’t let an attending sit in the lounge while the chief does the case.