Residency program has senior residents admit patients, and interns just write progress notes on them. I’m a bit frustrated, what is the silver lining?

[Latteandaprayer]

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So the program I’m doing my intern year at has the senior resident see, staff, and write the H&P for each new patient and put in any necessary consults right off the bat. Then the patient is assigned to an intern the next day who will do the rest (progress notes, discharges, new consults if needed, etc).

I know I’m complaining about doing less work. But I’m worried that not getting that initial attempt at working up patients is going to really make me a weaker physician. I know it sucks admitting, as a sub-I I had to see and “admit” my own patients. But at least I got to think of a differential, place those consults, and think about what I needed to do right now to get the patient in a good spot to survive the night.

What is the silver lining in this from an education perspective?

 

[wysdoc]

So the program I’m doing my intern year at has the senior resident see, staff, and write the H&P for each new patient and put in any necessary consults right off the bat. Then the patient is assigned to an intern the next day who will do the rest (progress notes, discharges, new consults if needed, etc).

I know I’m complaining about doing less work. But I’m worried that not getting that initial attempt at working up patients is going to really make me a weaker physician. I know it sucks admitting, as a sub-I I had to see and “admit” my own patients. But at least I got to think of a differential, place those consults, and think about what I needed to do right now to get the patient in a good spot to survive the night.

What is the silver lining in this from an education perspective?

As you gain more experience and gain the trust of the senior resident it is likely they will grant you more responsibility later on.
July and August all new interns are showing what they know/and don't know, so this practice is not surprising

 

[DrMetal]

What is the silver lining in this from an education perspective?

What's the silver lining? In 33 months, you'll be your own attending, and after you've practiced by yourself as an attending for a while, you'll realize how mis-guided much of GME was.

For now, push through.

 

[comp1]

This is entirely appropriate. Here's the thing, you don't have the experience to really be determining the treatment plan for patients yet. I get that some places let sub-i's play doctor and pretend to come up with a plan while actually running every single real decision made line by line by someone more senior. That's great, but not every setting has the time and energy to do all of that double work with interns or sub-i's. Your role, particularly just over a month after becoming a doctor, is to look at what the senior did carefully so that you're ready to do that sort of thing yourself next year.

 

[mistafab]

The fact that seniors do it means that you will do it.

Just stick to the program, follow the rules, and you will be trained. Go forth and prosper.

 

[Dral]

Take time to review why your senior did what they did on admission. This is your chance to learn without accountability of actions.

Complain if when you get to be a third year, they change practice and have the interns do all the admissions orders instead of you as a senior.

 

[NotAProgDirector]

Looking at your post history, I see you're in a prelim for this PGY-1, and then going to Neuro somewhere else. So you get the raw deal here -- only managing existing patients, never getting to do admissions. Personally I think this is a poor way to set up a residency program, and is unfortunate. But there;'s nothing you can do about it, and you'll get plenty of practice as a neuro PGY-2.

What you could do is, in the second half of the year, talk to the resident with whom you're working and ask to help with admissions. It would really help if you're efficient and all of the work/notes are done for the day by noon. Some residents may be open to it, and some not. Go with the flow.

 

[gutonc]

My program had this setup for the first 3-4 months of intern year. Then once everyone had a chance to be an intern on the medicine service, the 2nd time around it was a standard intern-first arrangement. I found it a little more humane while also being educational (assuming you had a good senior to start with).

 

[guytakingboards]

So the program I’m doing my intern year at has the senior resident see, staff, and write the H&P for each new patient and put in any necessary consults right off the bat. Then the patient is assigned to an intern the next day who will do the rest (progress notes, discharges, new consults if needed, etc).

I know I’m complaining about doing less work. But I’m worried that not getting that initial attempt at working up patients is going to really make me a weaker physician. I know it sucks admitting, as a sub-I I had to see and “admit” my own patients. But at least I got to think of a differential, place those consults, and think about what I needed to do right now to get the patient in a good spot to survive the night.

What is the silver lining in this from an education perspective?

I agree with everyone else in saying "trust the process" as well as "your time will come".

But also, step back a minute from the educational/learner role and think about the plight of the patient. Would you (or your loved ones) in an acutely ill situation want your initial assessment and work-up completed by brand new doctor 1 month out of med school? I can tell you with great certainty that there is wide spectrum of competency for new interns and medicine itself is built on graded autonomy. The system isn't intended to hold you back. It's intended to keep patients safe from the truly dangerous interns, of whom the program might not necessarily have sussed out already. Give it time as everyone has said and if you prove competent you will get asked to do more.

 

[dozitgetchahi]

Looking at your post history, I see you're in a prelim for this PGY-1, and then going to Neuro somewhere else. So you get the raw deal here -- only managing existing patients, never getting to do admissions. Personally I think this is a poor way to set up a residency program, and is unfortunate. But there;'s nothing you can do about it, and you'll get plenty of practice as a neuro PGY-2.

What you could do is, in the second half of the year, talk to the resident with whom you're working and ask to help with admissions. It would really help if you're efficient and all of the work/notes are done for the day by noon. Some residents may be open to it, and some not. Go with the flow.

I would agree that this is strange, and a bit of a raw deal if you’re an intern. I remember having to work through admissions from day 1 as an intern - it was absolutely a learning process, but one that was really important.

(To all those who are saying that it isn’t good for interns to be doing this - at the beginning of the year, the resident/attending should basically be at your hip anyway, watching everything that’s happening. I can remember what it was like early on as an intern - everything was discussed with the resident or attending, and usually the resident was heavily involved in the workups and management.)

That said, OP, it appears that you’re actually a neuro resident doing a medicine prelim. Which means all of this isn’t that important. You’ll be a neuro resident, and you’ll certainly be expected to do all the appropriate things there as a neuro resident.

 

[Latteandaprayer]

The fact that seniors do it means that you will do it.

Just stick to the program, follow the rules, and you will be trained. Go forth and prosper.

I’m a Neuro intern and this is my prelim year so I won’t have the chance to do that on gen med

 

[Latteandaprayer]

I would agree that this is strange, and a bit of a raw deal if you’re an intern. I remember having to work through admissions from day 1 as an intern - it was absolutely a learning process, but one that was really important.

(To all those who are saying that it isn’t good for interns to be doing this - at the beginning of the year, the resident/attending should basically be at your hip anyway, watching everything that’s happening. I can remember what it was like early on as an intern - everything was discussed with the resident or attending, and usually the resident was heavily involved in the workups and management.)

That said, OP, it appears that you’re actually a neuro resident doing a medicine prelim. Which means all of this isn’t that important. You’ll be a neuro resident, and you’ll certainly be expected to do all the appropriate things there as a neuro resident.

While I get your last point, the whole point of doing a prelim is to see, workup, and manage a lot of non-Neuro pathology. I was hoping to further refine my skills in approaching a chief complaint and arriving at a working diagnosis and treatment plan rather than be spoon-fed it to me. I could start on neurology right away and just read the primary team’s notes about how they arrived at a diagnosis. It feels like a waste of time to be a glorified secretary if I’m not involved in actually arriving at a diagnosis and treatment plan myself.

 

[mistafab]

Did not realize you were a prelim.

In that case, you are right. You are getting a watered down version of training, which is too bad. Even in psychiatry, I did 4 H&Ps start to finish per call on IM, like the IM interns did. In the long run it wont majorly effect your training in neurology. You just need to put extra effort into your learning of the cases you're working on if you want to get something out of it.

There is something unique in learning that happens when it is you in the drivers seat. But as an intern, you don't really realize all the safety rails that are in place for that to happen. A lot can go wrong in medicine.

 

[comp1]

I think another, more positive and likely accurate perspective, is that the experience of writing up a medicine admission is even less relevant than it would be for a categorical.

 

[NotAProgDirector]

If you have elective time, you could also ask to join the residents doing admissions as an elective.

 

[guytakingboards]

While I get your last point, the whole point of doing a prelim is to see, workup, and manage a lot of non-Neuro pathology. I was hoping to further refine my skills in approaching a chief complaint and arriving at a working diagnosis and treatment plan rather than be spoon-fed it to me. I could start on neurology right away and just read the primary team’s notes about how they arrived at a diagnosis. It feels like a waste of time to be a glorified secretary if I’m not involved in actually arriving at a diagnosis and treatment plan myself.

With respect, no that is not the point of your prelim at all. Those are lofty goals but I doubt there's a neurology PD in the country that expects or even wants their prelim to be grinding it out to become a top notch medicine intern.

Your goals as a prelim are:
-learn how to be a doctor/how to function in a hospital system
-learn the basics of diagnosis, work-up and management (as are applicable and transferable to neurology)
-learn *enough* medicine that you understand the line between medicine and referral specialists.
-be a functional and useful part of the services you're rotating through (as you are now a paid employee)

Most of those things don't require a full year, but that's just how the system is.

I don't want to be so crass as to say you're just cheap labor for a year, but there are many places that treat their interns as such. Your personal growth as a medicine intern (in regards to diagnosing/treating/managing an undifferentiated medicine patient) is something that basically no one else really prioritizes.

 

[dozitgetchahi]

With respect, no that is not the point of your prelim at all. Those are lofty goals but I doubt there's a neurology PD in the country that expects or even wants their prelim to be grinding it out to become a top notch medicine intern.

Your goals as a prelim are:
-learn how to be a doctor/how to function in a hospital system
-learn the basics of diagnosis, work-up and management (as are applicable and transferable to neurology)
-learn *enough* medicine that you understand the line between medicine and referral specialists.
-be a functional and useful part of the services you're rotating through (as you are now a paid employee)

Most of those things don't require a full year, but that's just how the system is.

I don't want to be so crass as to say you're just cheap labor for a year, but there are many places that treat their interns as such. Your personal growth as a medicine intern (in regards to diagnosing/treating/managing an undifferentiated medicine patient) is something that basically no one else really prioritizes.

I agree with a lot of this.

As I said, OP, there’s going to be plenty of time to learn neurology in neurology residency, and in the long run that’s what you really need to be worried about. If this was happening in your actual neurology residency, then I would totally agree with making a fuss about it. But as a neuro prelim, what you need to do is just get through the year and get on to the training that will actually matter for your career.

 

[RangerBob]

With respect, no that is not the point of your prelim at all. Those are lofty goals but I doubt there's a neurology PD in the country that expects or even wants their prelim to be grinding it out to become a top notch medicine intern.

Your goals as a prelim are:
-learn how to be a doctor/how to function in a hospital system
-learn the basics of diagnosis, work-up and management (as are applicable and transferable to neurology)
-learn *enough* medicine that you understand the line between medicine and referral specialists.
-be a functional and useful part of the services you're rotating through (as you are now a paid employee)

Most of those things don't require a full year, but that's just how the system is.

I don't want to be so crass as to say you're just cheap labor for a year, but there are many places that treat their interns as such. Your personal growth as a medicine intern (in regards to diagnosing/treating/managing an undifferentiated medicine patient) is something that basically no one else really prioritizes.

There is much value in learning how to do an admission at an intern. True, we're not efficient or great at forming a differential diagnosis (we shouldn't be horrible either). But one must start somewhere. I was a prelim-TY and while I was not expected to do all the admissions, I was expected to admit/follow my own patients (and present them to my senior, and attending). As such I did 1-3 admissions per day, which was very manageable. The senior still saw the patient (typically with me, after I had seen the patient on my own). They reviewed all medical management with me. If a consult was needed, we called them (after running it by the senior).

I'd liken it to I rode a bike with training wheels on it/dad's hand on the back of the seat. The senior had my back the entire time. Why can't the OP's program do such a thing? OP has spent two clinical years learning much of the basics of medicine, forming a differential dx, knowing when to call consultants, being a helpful member of the team, etc. They know enough basics to get on the bike. Why make them continue to sit out now? Throw them on the bike with proper supervision.

 

[Euxox]

I'm going to disagree with many of the others in this thread. Doing a medicine prelim year for neuro is different than someone doing a prelim year for ophtho or radiology.

General medicine issues *will* pop for neuro inpatients. If you're admitting someone to the stroke service and they declare themselves as septic shortly after hitting the floor, you're going to have pick a reasonable initial set of antibiotics, consider whether you're going to give fluids, think about when you need additional labs and what for. At most hospitals consulting the hospitalist at 3 AM is generally not an option.

It's unfortunate that OP's program isn't letting interns get those reps in. The saving grace is that neuro PGY2 can also be a time to learn those things, assuming that OP's senior residents didn't do their prelim at the same place.

 

[comp1]

General medicine issues will pop up in every specialty. The OP's program still sounds completely reasonable in how it manages intern education, prelim and categorical.

 

[Apollyon]

I remember a urologist in Brooklyn, when I was in med school, who said he picked up about 5 cases of diabetes per year, due to acquired phimosis (this was 25 years ago, before the renaissance of T2 DM).

 

[Euxox]

General medicine issues will pop up in every specialty. The OP's program still sounds completely reasonable in how it manages intern education, prelim and categorical.

What general medicine issues does a diagnostic radiologist handle? And for a specialty like derm or ophtho, you will always be a consultant, never a primary, and it's not your responsibility to handle general medical issues. Neurology is a patient facing specialty that can be primary, and that makes them different than most other specialties that do a medicine prelim.

 

[s5260205]

Speaking from personal experience which likely is similar across programs, there is general inertia in training prelim interns compared to categorical interns, in that unless they are absolutely horrendous with significant professional issues, most places would rather send them their way instead of dealing with probation/disciplinary actions. This results in questionable residents who are promoted to PGY-2 in neurology when they would not have been if they were categorical.

What this means is that education often falls on your shoulders. Despite senior doing H&P, there is still a lot you can learn - both the practical part of "doctoring" (e.g., EMR, note completion, calling consults, etc.) and medicine foundation. You can request increasing level of responsibility as you become more comfortable. There is a lot of self-learning in medicine which would only increase as you progress through training and eventually attending-hood.