Quantcast

Residency is What You Put Into It?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

zeloc

Senior Member
15+ Year Member
Joined
Aug 22, 2003
Messages
406
Reaction score
28
At several places where I interviewed, I asked residents about how many procedures they get to do, and have gotten responses like "if you're proactive, you can get a lot of procedures," or "residency is what you put into it," even at some of the top programs. I have also gotten these kind of answers when asking about the learning environment, critical care experience, etc.

Now, I interviewed at another program where several of the second-years said they got to do tons of IJs, subclavians, femorals, and just got so used to treating end-stage complications of diseases (on unit months) that the rest of medicine just became so easy. They didn't have to "search" for procedures, there were just tons of procedures to do so they had to gain experience. They seemed super competent and just gave off a very different feel than the residents who said that they had to work to get procedures, or who did mainly IJs and got to do 1 or 2 subclavians, or whatever.

Has anyone else noticed these differences at programs? Is it really true that residency is what you put into it or is it just better to just go to a really volume-intensive or front-loaded residency program, even if it will be more difficult while it is going on?
 

Amelia

Full Member
10+ Year Member
Joined
Jan 15, 2008
Messages
38
Reaction score
1
You can see (do) a lot of procedures as a fourth year if you are "proactive" i.e. if you want to, it is basically see one, do one and then teach one. Putting in an IJ or Sub-clavian is something that a midlevel resident at least needs to be able to do, and I'm sure you would get the opportunity to do it, but after you have done 3 or 4 I would think that you've gone pretty far up the learning curve with this procedure, there is A LOT more to medicine than this, and although it sounds cool to be confident with this procedure, everyone learns how to do it by the end of residency, so I wouldn't based a decision on a residency program on this. . . i.e. I wouldn't expect to find a chief resident or final year resident complaining about not having done enough central lines at most (all?) programs. . . a lot of programs have checklists for procedures, i.e. a certain amount you have to do. While putting in a central line may seem like a highly specialized sought out skill, it is not, and something you can learn anywhere . . . You could come into the hospital on your day off as a resident, sit in the ICU and just ask to do all the central lines or whatever going on that day, . . or just look for opportunities during your residency, maybe it takes on average 15 minutes to put one in so if after three years you haven't done more than 2 then yes it is your fault for not being "proactive", but this isn't like surgery where if you do two times as many colectomies you really are more competent, I doubt there is a difference between doing 40 and 80 central lines in terms of being a good internist as most internists don't do these procedures regularly as they are done on inpatients and so easy to do that residents teach residents how to do them (i.e. no big deal) . . . people will be more impressed if you know the latest treatment and management of diabetes than if you said you made sure you did 80 instead of 40 central lines during residency, . . . again if it takes you at most 30 minutes per central line to prep and read cxr later that is only 40 hrs of your life during residency . . . (I'm a fourth year and I can put in a subclavian, IJ, a-line, peripheral line (some students can't even get a peripheral iv so I list it) . . . but I am not deluded to think that I am "competent" in terms of managing an icu patient yet, . . . doing these procedures is like learning to tie your shoes, managing patients is like getting a license to drive.

ICU teaches you a lot, but you really focus just on critical problems in the ICU i.e. keeping the patient alive, not "let's figure out if our patient has SLE or some other connective disease disorder" . . . there is an art to general IM ward medicine, i.e. consulting and planning management of these patients which have different focus of the clinical management, for a resident to say that handling ICU patients makes general medicine wards easy I think more reflects perhaps the amount of work involved in one icu patient versus one general medicine patient, . . . but obviously different skills are needed on the wards than in the icu. . . although a general medicine wards patient will survive your care, there are other things you need to address like treatment of chronic diseases, outpatient planning, consulting, and sometimes just trying to diagnose which for some medicine patients is hard even for attendings, i.e. I have seen many "straight-forward" ICU patients i.e. sepsis, ards, etc . . . which appear less complex than say an inpatient with a dozen chronic diseases and undefined hematologic problems who actually needs more evaluation and workup while the ICU patient just needs monitoring more frequently but the management is more or less a closed case.

I think that residents who do best are the ones who ask "What is the big picture of what is happening with my patient?" and then they are able to come up with a coherent plan and fill in the details, instead of just being an intern their whole residency i.e. treating lab values like low hgb and not appreciating how each patient's medical problems are unique or why certain management decisions are made. I think the worst residents complain why some attending did this or that to their patient, complain that it doesn't make sense, and then don't try to figure out why the patient was managed that way. Obviously, medicine requires a lot of reading, so part of being good is reading up on your patients and going to conference.

I wouldn't go to a "Frontloaded" program unless you can do a large number of patients efficiently, I took huge numbers of patients as a sub-I and on other electives so that I can deal with a dozen patients and know what is happening with all of them, a lot of medicine is pattern recognition so seeing how a lot of patients are managed is good this way, if you haven't done this then maybe go to an easier program I guess, it doesn't seem to matter as work expands to fill the available time whether you have a dozen patients or 6 . . .
 

lemonade02

Full Member
10+ Year Member
Joined
Sep 24, 2007
Messages
136
Reaction score
1
thanks amelia..i found this post quite inspiring as an ms4 about to be a 'tern
 

zeloc

Senior Member
15+ Year Member
Joined
Aug 22, 2003
Messages
406
Reaction score
28
Very interesting post amelia...

I've never had to manage a large number of inpatient IM patients at the same time, but I know that I can and would be able to and would never choose an "easier" program just because I haven't done it as an M4. My question is whether I would learn more having 12 patients at a time than 6 patients at a time for most of residency.

I'm actually more interested in the complex diagnoses, the long-term planning, all of the very difficult "medicine" topics, and reading your post, I think I've identified a mental bias that I've got toward procedures just because I feel a lot better in other areas of medicine, and perhaps also because there are medicine residents where I've done my rotations who are occasionally criticized by surgery residents on procedures and just don't seem as competent as residents I've seen at any university program, but it isn't fair to compare a community hospital to any university program. I know that all programs have requirements for procedures, but there is a big difference between getting the minimum number done and doing twice those, and it would only make a difference during the icu months, which aren't a lot of time anyway. I would also think that if there are a lot of procedures, the person would have to get forced into being efficient on the rest of the patients rather than allowing the time to get filled up by a fewer number of patients.

My question is more, doesn't going to a more volume-intensive program contribute to not only more procedures and ICU patient experience, but also to more learning on the wards, etc., about all of those important topics you have mentioned, simply because there are always many more patients? On the other hand, having fewer patients means more time for reading and learning, but I wonder if there is a difference in the quality of physician that graduates from a more intense residency program, just being more competent than going to a university program that doesn't have that reputation.
 

Amelia

Full Member
10+ Year Member
Joined
Jan 15, 2008
Messages
38
Reaction score
1
Very interesting post amelia...

I've never had to manage a large number of inpatient IM patients at the same time, but I know that I can and would be able to and would never choose an "easier" program just because I haven't done it as an M4. My question is whether I would learn more having 12 patients at a time than 6 patients at a time for most of residency.

I'm actually more interested in the complex diagnoses, the long-term planning, all of the very difficult "medicine" topics, and reading your post, I think I've identified a mental bias that I've got toward procedures just because I feel a lot better in other areas of medicine, and perhaps also because there are medicine residents where I've done my rotations who are occasionally criticized by surgery residents on procedures and just don't seem as competent as residents I've seen at any university program, but it isn't fair to compare a community hospital to any university program. I know that all programs have requirements for procedures, but there is a big difference between getting the minimum number done and doing twice those, and it would only make a difference during the icu months, which aren't a lot of time anyway. I would also think that if there are a lot of procedures, the person would have to get forced into being efficient on the rest of the patients rather than allowing the time to get filled up by a fewer number of patients.

My question is more, doesn't going to a more volume-intensive program contribute to not only more procedures and ICU patient experience, but also to more learning on the wards, etc., about all of those important topics you have mentioned, simply because there are always many more patients? On the other hand, having fewer patients means more time for reading and learning, but I wonder if there is a difference in the quality of physician that graduates from a more intense residency program, just being more competent than going to a university program that doesn't have that reputation.

I am not sure that there are IM programs where the interns have only 6 patients at a time, maybe more like 8-10 a day for a minimum I would guess. It does matter the number of patients in terms of if you are just starting out and you get 14 patients and then the attending asks you what you did about the trend in bilirubin say with one patient and you respond you were busy admitting five patients that afternoon . . . it is like being an air track controller I would guess, i.e. you need to know exactly where all the "planes" are, what they are doing, which ones are ready for a "take-off" like getting a CT or something or discharge, if you haven't done it before you will get "swamped", if you have done it before then you immediately classify patient A as having ESRD on HD on M/W/F, cellulitis with abx day # . . . and you just absorb everything important about blood cultures etc. . . and stuff pending and are already working on discharge from day 1 and have already started to plan this or that consult. I think most interns on day one are pretty disorganized in terms of knowing everything about their patients and wish they had fewer patients so they could look like they are more on top of things. I think it helps to take a lot of patients during medical school so that you have simply seen more stuff and can handle a dozen patients or more . . . In terms of being more competent, if you have 6 patients and you read about all of them and now know CHF inside and out including all of the latest clinical trials versus if you just try to keep 16 patients alive and don't read up on them then you would be more competent as a physician with the six patients right? When you are a senior resident then you really learn as the attending asks you what did with Ms. Smith's chest tube or results from chest CT, i.e. you better display good clinical knowledge and management skills. So I think that being at a residency program with drastically more patients will not give you a huge edge in terms of "competency" in internal medicine, you may feel more stressed out with working up and managing huge number of patients. I think that at the higher volume load programs attendings don't (can't ) have the luxury of discussing every patient's care in depth with you, whereas if there is more time you can discuss the care of a patient with the attending more indepth, a lot of times senior residents do this or that because that is how it is done at their institution or that is what Dr. so and so said to do, but they don't really understand why. I think competency also depends on the quality of teaching you get, say you go to an institution with a fabulous hem/onc service that teaches residents everything about the patients on the hem/onc service and about common hematological and oncological problems, then you have learned more than a resident who has seen maybe more cases of sickle-cell disease but hasn't discussed them with an expert clinician teacher and can't manage such patients on their own, so quantity does not equal quality. Say one resident graduates from John Hopkins IM program and can handle large patient loads (like most residents can in the end), but has seen maybe 10% less patients than someone who went to a more rough and tumble program, . . . I would argue that the training at John Hopkins is better as this resident was taught by supposedly outstanding faculty, likely saw more rare cases than the resident at rough and tumble who may not have had the faculty interaction that you get at Johns Hopkins. Remember that as an attending you will need to "see" keep track of maybe 30 patients a day when you are managing multiple resident teams, but it gets easier as you recognize patterns more easily and identify important management decisions.
 
Top