resident autonomy

[balaguru]

Here's a front page article from the Dallas Morning News regarding resident autonomy at UTSW. Obviously, I'm not going to comment on the article or our institution other than to say I believe we have appropriate supervision. I was wondering if anybody would like to comment on some of the practices mentioned in the article. For example, staff presence in the OR, when to page staff during the case, etc. Also would like to know to what degree residents out there are staffing consults like lines, abscesses that are really pimples, etc.

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[ESU_MD]

What an interesting article, seems like they did alot of research.

Parkland sounds like a really great place to train. There needs to exist in every program a place like this where residents can run the place. Few truly exist in the country anymore- LA, Kings County, Ben Taub, Grady, Cook to name a few.

Not everyone is able to be a faculty member at a place like this. Larry Gentilello and the cronies he hired sound like they would be much better off in private practice. Throwing residents under the bus demonstrates that you may not be able to be a good teaching attending.
It takes balls to let residents do stuff in the OR and as staff you have to accept the responsibilty if the screw it up.

I have had the honor of training at one the old school training institutions. Yes- I have seen chiefs taking juniors through lap choles, appy's etc..
Even though there is great autonomy, it is not uncontrolled.
Most of the time, the bad residents are well known and THEY are closely watched and nobody will let them get a patient in the OR without the staff being aware, or get too far. on the other hand, the well respected chiefs have greater leeway.

 

[45408]

Nonetheless, The News obtained information on patient death rates at Parkland, where residents serve as "house staff." Data that compare teaching hospitals across the country show that Parkland's performance is average. In some key measures of patient mortality, however, data show the hospital was near the bottom of its peer ranking.

The News also found evidence that residents had botched other abdominal surgeries and amputated legs before faculty physicians even knew patients were in the operating room. Emergency room patients have been discharged after residents misread tests or failed to detect serious injuries, such as broken necks. Others have been subjected to unnecessary drugs or radiation because of misdiagnoses.

The head of UT Southwestern's general surgery residency program once said it was "OK for residents to make mistakes" on patients "even if they could have been avoided with better faculty supervision," according to notes taken by a faculty surgeon and later included in court records.

Ugh, the media publish stuff like this, and the lay people just don't really understand what they're reading.

First, I'm sure many/most hospitals have "some measures of mortality" that are below average, so that stat seems meaningless.

Second, how many patients with "broken necks" were discharged from the ED? and what is a "broken neck"? A displaced odontoid process fracture or a non-displaced C6 process fracture?

Third, what kind of mistakes? The wrong dose of Lasix that resulted in inadequate diuresis overnight, or letting a trauma patient exsanguinate?

 

[45408]

This article presents the most profound problems in medicine which is the lack of knowledge with respect to pain issues. Ms. Limon has the much maligned but treatable "complex myofascial pain syndrome" cause by a multitude of overlapping issues. These issues plague the health-care system since the modern era. Lack of the ability to discovery deficiencies, eliminating suspected poisons from the patient system, doctors who are not well equipped with the wisdom, compassion and lack the proper tools and training and finally the lack of time needed to address the overwhelming stresses in a patient's life.

Ms. Limon's problem is treated with a hands-on approach releasing all abdominal area myofascial trigger points. Restore her deficiencies with vitamins, minerals and trace elements, specifically magnesium, copper, zinc, selenium and lithium. Assessing the situation and eliminate any potential poisons. Establish a wellness program that is guided by the patient needs.

You know, I was thinking that the patient might be selenium deficient.

 

[SouthernSurgeon]

Not everyone is able to be a faculty member at a place like this. Larry Gentilello and the cronies he hired sound like they would be much better off in private practice. Throwing residents under the bus demonstrates that you may not be able to be a good teaching attending.
It takes balls to let residents do stuff in the OR and as staff you have to accept the responsibilty if the screw it up.

Read his blog before you judge. There is some scary stuff. Makes me glad I ranked UTSW so low.

 

[dynx]

Here's a front page article from the Dallas Morning News regarding resident autonomy at UTSW. Obviously, I'm not going to comment on the article or our institution other than to say I believe we have appropriate supervision. I was wondering if anybody would like to comment on some of the practices mentioned in the article. For example, staff presence in the OR, when to page staff during the case, etc. Also would like to know to what degree residents out there are staffing consults like lines, abscesses that are really pimples, etc.

I don't know...hard to judge from the article.
At my program 3rd years take interns through lap chole's with the attending popping thier head in to take a look at the anatomy..Lap appys, amputations (bka and below) skin grafts etc are all primarly resident done alone. Larger cases all have attendings present. I think this is an appropriate level of supervision although some things do happen.

Lines, I and D's...ussually the attending made aware whenever you see them next, certainly not bothered before unless they call to tell you about a patient they want a line in.

 

[waxedapathetic]

i did many surgery rotations at a major academic medical center in a major city in texas. i developed a sentiment similar to that of the authors of the dallas morning news article regarding the kind of care offered at my institution. i have little doubt the same thing is happening at parkland.

after coming up to the north to do residency, the difference is clear.

you get to operate a lot in the south, in general. however, the lack of supervision could hinder you from learning the correct way to treat a patient. i really believe that's true.

parkland uses an old model. in this case, i think the new model is better for patients ... and i think residents can still learn.

 

[dpmd]

Residents not even notifying an attending that they are starting a case seems odd to me. At my institution we don't have a specific list of procedures that can be completed without faculty supervision. Instead they go off a graduated responsibility thing where the attending has the final say if the particular resident is advanced enough to handle it (although certain things, like simple I+D's and basic lumps/bumps the OR team won't even question it). We still give the attending a heads up that we are starting, and more often than not even for really simple stuff they will poke their heads in and see if everything is good. We have residents teaching residents for lots of things, but faculty are scrubbed in for more complex cases(or more time sensitive things-trauma ex lap can be very simple, but things might pop up that need immediate attending level decisions). That said, I am a fourth year and I did an open appy the other night where the staff scrubbed with me. It was still an educational experience despite my prior cases, and I wasn't threatened by his presence.

There has to be a middle ground between autonomy that may be too free, and supervision that leads to inadequately trained residents. I think the key is faculty that are confident enough in their own skills to feel comfortable enough to give you some room to work. Sometimes a well placed "perhaps you might try to do this now" is all it will take to rein in a case that is going astray.

With appropriate training early on, I don't see a need for the faculty to be called for every line, chest tube, bedside I+D/biopsy, or decision for admission/discharge. Beginning the second half of second year we start night float and are the senior surgical person in house. You can be certain there are more calls to the attending or chief at home in those first months versus later on. If we were never given that responsibility though, I would think we would be ill prepared when we go out into the world. I think that would be much more unsafe for patients in the long run than giving out more responsibility when there are faculty around to rescue you.

 

[Pir8DeacDoc]

Our paging systems pages the resident and attending into the room when the patient arrives, so they are always aware. Plus, our hospital requires the attending to be in the room and do the "time out" prior to the start of the case. Once that official act is done they are free to "supervise" in whatever way they feel is best.

I recall interviewing at a Southern program (I'm a southerner) and they were quite proud of the fact that the indigent patients were seen in a resident clinic and the resident did their cases. I would certainly appreciate the autonomy but we owe it to the patients and society in general not to take advantage of the underprivileged like that. We can have autonomy as resident surgeons and still provide excellent surgical care.

 

[opr8n]

Our paging systems pages the resident and attending into the room when the patient arrives, so they are always aware. Plus, our hospital requires the attending to be in the room and do the "time out" prior to the start of the case. Once that official act is done they are free to "supervise" in whatever way they feel is best.

I recall interviewing at a Southern program (I'm a southerner) and they were quite proud of the fact that the indigent patients were seen in a resident clinic and the resident did their cases. I would certainly appreciate the autonomy but we owe it to the patients and society in general not to take advantage of the underprivileged like that. We can have autonomy as resident surgeons and still provide excellent surgical care.

if they are being cared for by a chief resident, i dont think that is a dis-service, they will be an attending soon and should know what the heck they are doing, right?

 

[dynx]

seen in a resident clinic and the resident did their cases. I would certainly appreciate the autonomy but we owe it to the patients and society in general not to take advantage of the underprivileged like that.

Owe them what? How about an option. "Hi I'm Dr. DYNX, im the senior resident...I'll be seeing you in clinic then doing your elective operation. AND PAYING FOR IT WITH MY TAXES. You don't like it....there's the door"

Thats what we owe them. The choice. They get shot in the chest an attending is going to be there. They want something elective for free, they owe me and the rest of society thats footing the bill the education of residents. And a shower preferably.

 

[45408]

I recall interviewing at a Southern program (I'm a southerner) and they were quite proud of the fact that the indigent patients were seen in a resident clinic and the resident did their cases. I would certainly appreciate the autonomy but we owe it to the patients and society in general not to take advantage of the underprivileged like that. We can have autonomy as resident surgeons and still provide excellent surgical care.

I view it as being given a free (or deeply discounted) service, which is hardly being taken advantage of. There are many things that PGY-5 should be able to diagnose and treat independently, and the alternatives might be not getting the treatment at all or going deep into debt for it.

I resent the implication in the article that residents "experiment on their patients" or that the poor people are our "guinea pigs." I don't see how you think they're being "taken advantage of." Unless you know people that don't treat their patients with the same level of care based on their ability to pay, then it seems like they're getting surgery from someone with less experience.

 

[Pir8DeacDoc]

I hear where you guys are coming from. My impression is it wasn't just the SR residents doing the clinic and operating. That would certainly make a difference in my mind.

I still think we shouldn't change our treatment of patients based on their socioeconomic status. We should maintain as much autonomy as possible as safely as possible no matter the patient's station in life. I've operated on physicians kids and I've operated on homeless drunks, it should be the same no matter. Otherwise I don't see how it can be anything but treating poor people like guinea pigs.

 

[dpmd]

All of our patients are seen at a resident run clinic (there is an attending available if needed) where the chief is in charge, but patients are seen by anything from a med student to a fourth year. When it is a more junior person the chief sees the patient too. Of course, given the fact that we have no private insurance contracts our patient base is primarily medi-cal, self pay, or indigent care. In the event we have an insured patient in house (we are the designated trauma facility for kaiser, and there are occasional emergent admits) they are not treated any differently. They are seen by residents (with a medical student often the first person to see them) and the attendings supervise their care (but often don't get too involved).

I have seen at other hospitals where there exists a division between private patients (insured typically) and service patients (typically uninsured). I guess they must have reasons for doing that, but that does make things look more unsavory to outside viewers.

 

[dpmd]

I hear where you guys are coming from. My impression is it wasn't just the SR residents doing the clinic and operating. That would certainly make a difference in my mind.

If they are getting a lipoma excision, or something similarly easy I wouldn't see any problem with them letting the intern do the case (with supervision). Letting the intern loose on a hepatic resection or something, not so much.

 

[Doc013]

"The 13 who raised concerns internally worked or trained, collectively, at 32 other medical schools and hospitals, including Yale, Harvard and Johns Hopkins, before coming to Dallas. They represented seven clinical areas and departments at UT Southwestern or Parkland."

These are physicians making allegations against Parkland and across several departments. I know lots of people who have trained at Parkland, and my sense is that this article is spot-on. These concerns are real and serious.

 

[Socrates25]

Some of Limon's medical records, reviewed by The News, suggest a link between her persistent symptoms and the surgery.

Yes, based on the EXPERT MEDICAL OPINION of a ****in news journalist. Bunch of pretentious idiots. They dont know jack about medicine.

Generally, such symptoms indicate the patient needs another surgery, said Dr. Martin Makary, an associate professor of surgery at Johns Hopkins School of Medicine who specializes in laparoscopic procedures. He did not review Limon's records and stressed he was not speaking about her case in particular.

In other words, he doesnt know what the hell he is talking about and he should have NEVER been cited for this article. His testimony is absolutely irrelevant.

"You're obligated to go in there and do another operation when things cool down," he said. "There's no point in waiting to see if the symptoms get better." At Johns Hopkins, faculty surgeons must be present at the start of surgery and stay through to the end, except for the closing,Makary said. Residents may operate, he added, but faculty are scrubbed and standing nearby, ready to take over if trouble develops.

The bolded section is a bald-faced lie. I went to Hopkins and while its true that all cases have attendings come into the room for at least part of the procedure they are almost NEVER there from the beginning until closing starts.

 

[former military]

when I was a resident I had tremendous autonomy. I saw clinic patients and operated without supervision. this was 1995-2001 and laws or rules were different. there was always a staff's medical license on the hook for everything I did whether they knew it or not or cared or not. They always had the opportunity to supervise or check on me. Big cases they chose to come in to do because they wanted to... it was fun for them....
I was the baby being thrown into the pool and learned to swim on my own.

it is a different time legally and money wise and I staff residents differently. I have to cosign all their notes and preops and am responsible. I preop all but the simplest cases because my carefully worded consents are much better than theirs and that is so protective in getting successfully sued. i dictate my own op notes for this same reason. the residents think I am helping them with scut but in reality I don't trust them enough to make them airtight. I don't think they appreciate the details of the complex cases to know what to dictate accurately. It isn't what you do it is what you dictate that matters. the only people who read an op note is research people doing a study, attorneys, and me.

I also scrub for every case- the whole case. the patient is paying for my 14 years of doing surgery not a pgy 3-6 to do the case and I think they deserve this. I wouldn't want an operation on my gall bladder by a pgy 2 unsupervised. I let them do 0-100% of the case depending on the following variables
1) they have seen the case
2) they have done the case with me before
3) they can follow my explicit instructions
4) they can technically perform my explicit instructions
5) they care about the preop and post op consequences and follow up
6) they don't argue with me during the case or try to teach me how they do it or another staff does it.

I can watch them do the entire case or they can watch me do the entire case depending on these six criteria. I don't care what year they are.

if a resident doesn't know the preop history or I talk to the resident about a case from 2 weeks ago and they don't know the pathology on the case we do together that tells me a lot. I also see the long-term results and complications and outcomes from my surgery and the resident doesn't. he or she is off to another rotation never to see the patient again. So I know the outcomes of my techniques.

 

[Leforte]

Great words from Former Military. Perhaps I should print them out and give them to the residents as they rotate on service....

 

[blue2000]

it is a different time legally and money wise and I staff residents differently. I have to cosign all their notes and preops and am responsible. I preop all but the simplest cases because my carefully worded consents are much better than theirs and that is so protective in getting successfully sued. i dictate my own op notes for this same reason. the residents think I am helping them with scut but in reality I don't trust them enough to make them airtight. I don't think they appreciate the details of the complex cases to know what to dictate accurately. It isn't what you do it is what you dictate that matters. the only people who read an op note is research people doing a study, attorneys, and me.

I also scrub for every case- the whole case. the patient is paying for my 14 years of doing surgery not a pgy 3-6 to do the case and I think they deserve this. I wouldn't want an operation on my gall bladder by a pgy 2 unsupervised. I let them do 0-100% of the case depending on the following variables
1) they have seen the case
2) they have done the case with me before
3) they can follow my explicit instructions
4) they can technically perform my explicit instructions
5) they care about the preop and post op consequences and follow up
6) they don't argue with me during the case or try to teach me how they do it or another staff does it.

I can watch them do the entire case or they can watch me do the entire case depending on these six criteria. I don't care what year they are.

if a resident doesn't know the preop history or I talk to the resident about a case from 2 weeks ago and they don't know the pathology on the case we do together that tells me a lot. I also see the long-term results and complications and outcomes from my surgery and the resident doesn't. he or she is off to another rotation never to see the patient again. So I know the outcomes of my techniques.

New attending here. Totally agree with this. Some people in my program think particular attendings are "hands on" when really it's a lack of trust of the resident.

 

[JackADeli]

...i dictate my own op notes for this same reason. ...I don't think they appreciate the details of the complex cases to know what to dictate accurately. ...the only people who read an op note is research people doing a study, attorneys, and me...

That is a very unfortunate loss of learning opportunity and sounds like an easy way out of teaching. My attendings had me dictate 90+% of the time.

None of my dictations were final end product until signed off by the attendings. They then went back, reviewed, ammended/addendum my errors and pointed out the fact that I failed to identify or note x, y, & z pertinent points. I learned very quickly the critical components of the case. One attending had me dictate a whipple as a PGY2 holding hook for the chief resident... that dictation was a learning moment to be sure! It did however take effort on the teaching attendings part.

I graduated circa 2008. Most of the programs I am in contact with, residents still dictate in the manner I describe above.

 

[former military]

That is a very unfortunate loss of learning opportunity and sounds like an easy way out of teaching. My attendings had me dictate 90+% of the time.

None of my dictations were final end product until signed off by the attendings. They then went back, reviewed, ammended/addendum my errors and pointed out the fact that I failed to identify or note x, y, & z pertinent points. I learned very quickly the critical components of the case. One attending had me dictate a whipple as a PGY2 holding hook for the chief resident... that dictation was a learning moment to be sure! It did however take effort on the teaching attendings part.

I graduated circa 2008. Most of the programs I am in contact with, residents still dictate in the manner I describe above.

In the reality of medical records, all my operations are smart phrased. so I type five key strokes and I have a complete two page dictation note that is 95% correct and I fill in a couple blanks. This ensures that everything I want to be there and I can put the exact findings or deviations in. this takes me about 40 seconds. Reviewing what the residents dictate takes a long time and I just don't have that time. I give all of the residents my smart phrases of the common surgeries I do as well as the preop consents covering all bases. I give them this the first day on the 3 month rotation. Most never read these. I know because if they did, they wouldn't ask me questions during the case of how I do things or what things I do next. So they get the opportunity to learn right up front. I suggested they print these out and put all the various staff individual notes in their surgical atlas and review both before we go to the OR.

 

[opr8n]

when I was a resident I had tremendous autonomy. I saw clinic patients and operated without supervision. this was 1995-2001 and laws or rules were different. there was always a staff's medical license on the hook for everything I did whether they knew it or not or cared or not. They always had the opportunity to supervise or check on me. Big cases they chose to come in to do because they wanted to... it was fun for them....
I was the baby being thrown into the pool and learned to swim on my own.
.

if that was good enough to train you back then, than why is that not good now?
I know the legal climate is different, and the public has greater awareness of resident training, but honestly, why is it that things changed soo much in the last decade, when they were fine the many decades before that?

I personally think the fear is gone from residency. The heirachy has been destroyed. Absite scores mean nothing for advancement in most places
AND MOST OF ALL, the expectations from attendings has fallen so much for residents. Our surgical residncy training system is falling down in this country and it will continue on that path unless something changes. The people who will be most affected will be the patients, as the care will not be as good

And let me ask this ...
why is it that a PGY-4-5 dosent deserve autonomy, but one day after the end of residency that same resident who didnt get to learn independence when they should is all of asudden so much more preparred to operate independently???

 

[JackADeli]

...i dictate my own op notes for this same reason. ...I don't think they appreciate the details of the complex cases to know what to dictate accurately. ...the only people who read an op note is research people doing a study, attorneys, and me...

...all my operations are smart phrased...this takes me about 40 seconds. Reviewing what the residents dictate takes a long time and I just don't have that time. I give all of the residents my smart phrases ...Most never read these. ...So they get the opportunity to learn right up front. I suggested they...

That is all so very unfortunate. You have to do what you have to do, but... What I am reading is
~ I have residents and I don't have time to teach them. So, I give them reading material to teach themselves if they like.
It is pretty classic
~ I do enough teaching by them being in the OR.
Plenty of attendings old and new still make this argument to not actually do more then operate. Yes, having them dictate and then taking time to read and instruct takes time... By your own words, your residents haven't been taught and thus can't properly dictate. You are just perpetuating the problem by saying they can't dictate, it takes to much effort to have them dictate and you review, so you give them reading material that they don't read.

 

[former military]

That is all so very unfortunate. You have to do what you have to do, but... What I am reading is
~ I have residents and I don't have time to teach them. So, I give them reading material to teach themselves if they like.
It is pretty classic
~ I do enough teaching by them being in the OR.
Plenty of attendings old and new still make this argument to not actually do more then operate. Yes, having them dictate and then taking time to read and instruct takes time... By your own words, your residents haven't been taught and thus can't properly dictate. You are just perpetuating the problem by saying they can't dictate, it takes to much effort to have them dictate and you review, so you give them reading material that they don't read.

I tried to teach them to dictate. At the conclusion of the case, I would ask them to dictate the case face to face to me as we closed the skin. I would give them two to five minutes to say out loud what we had done.... correcting them at the end. I didn't get far with this and stopped.

resident autonomy and the topic of the original post is very interesting. Why is it that one day you are a chief resident without the autonomy to do what you want unsupervised and unchaperoned... the next day you graduate and can do this? Are you better the next day or smarter or more technically gifted? No, there are just rules and laws. Back in the early days there weren't the plethora of laws or legal risks. the public was more likely to live with the complication of the junior resident if you had surgery at gotham hospital and they probably couldn't sue you. There are residents who operate better than some of the staff I know. I didn't make the rules of who is legal to operate solo and who isn't. I just live by them. At my hospitals, historically there has to be a timeout and the staff has to be in the room before anesthesia will put the patient to sleep.

I am not an expert on parkland hospital but I do imagine if Jerry Jones or some oil exec gets dragged into the ER some PGY-3 doesn't bounce them up to the OR for surgery. It seems that is more likely to happen to the indigent population like the person featured in the article and the rich get the best surgeons or more experienced surgeons and the poor get what they get and should be happy about this. If a junior resident can take someone to the OR unbeknownst to the staff, why even have accreditation at all? Just let any graduating medical student who wants to do surgery hang out a shingle, get hospital block time and operate it up.

My reaction to the parkland article is that the system has deemed the underserved Dallas metro population one giant pig lab for people to figure it out and gain confidence on their own.

 

[45408]

Reviewing what the residents dictate takes a long time and I just don't have that time.

So why work with residents at all?

 

[45408]

I tried to teach them to dictate. At the conclusion of the case, I would ask them to dictate the case face to face to me as we closed the skin. I would give them two to five minutes to say out loud what we had done.... correcting them at the end. I didn't get far with this and stopped.

So you put them on the hot seat and give them the bare minimum amount of time it actually takes to get all those words out, and then you say "**** it, not worth my time"? If you don't want to spend the time teaching them, why not get a private practice job?

Back in the early days there weren't the plethora of laws or legal risks.

Of 2000-2001?

 

[JackADeli]

...i dictate my own op notes for this same reason. ...I don't think they appreciate the details of the complex cases to know what to dictate accurately. ...the only people who read an op note is research people doing a study, attorneys, and me...

...all my operations are smart phrased...this takes me about 40 seconds. Reviewing what the residents dictate takes a long time and I just don't have that time. I give all of the residents my smart phrases ...Most never read these. ...So they get the opportunity to learn right up front. I suggested they...

I tried to teach them to dictate. At the conclusion of the case, I would ask them to dictate the case face to face to me as we closed the skin. I would give them two to five minutes to say out loud what we had done.... correcting them at the end. I didn't get far with this and stopped...

You are giving example after example of how one goes about blaming the residents for the lack of teaching in residency. You are using multiple approaches almost guaranteed to fail and then washing your hands of the duty to teach... and sending the resident home with reading material to self teach. Bravo.

...If you don't want to spend the time teaching them, why not get a private practice job?...

cause then you don't have residents!