Resident lead residency

[docman85]

---

Members don't see this ad.

I was curious about other resident ran residency programs that grant a lot of autonomy starting as an intern. I know there is a list of county programs out there, but I know not all county programs are like this. I know Uf-Jax, Emory, NOLA seem to grant a lot of autonomy and with applications getting ready to go out I just want to make sure I have all the programs included when i apply.

 

[jbar]

Careful what you wish for. Next thing you know you are at the CT scanner by yourself week 2 of intern year with an intubated patient on an intra-aortic ballon pump and a code bag full of meds. Just saying, you want some autonomy, but feeling like you don't have backup is no fun.

Nothing against the programs you've mentioned, don't know them. But you want to make sure you have some supervision with your autonomy.

 

[Groove]

I was curious about other resident ran residency programs that grant a lot of autonomy starting as an intern. I know there is a list of county programs out there, but I know not all county programs are like this. I know Uf-Jax, Emory, NOLA seem to grant a lot of autonomy and with applications getting ready to go out I just want to make sure I have all the programs included when i apply.

You've got your priorities back assward. The nurses will know more about managing patients when you start residency than you do. Autonomy is all fine and good later on in residency when you have learned the majority of your clinical medicine but you don't want it your first year. You learn by doing... but you learn from experienced mentors who have been doing EM for a looong time and have seen just about everything. Take advantage of your learning as much as you can during residency. Even when you are finishing and feel comfortable on your own managing just about anything, you'd still be a fool not to humble yourself and listen to the guys who have been doing this a LOT longer than you.

My first day as an intern, I had call that night in the NSICU and had to put in a subclavian CVL that I had learned how to do that day, by myself... in an ICU full of 20+ patients where I was the only resident. 2 months later... I had to start a cric on a SICU pt who the respiratory tech dislodged the ETT during the night and pt crashed and I could not re-intubate. Anesthesia and Surgery chiefs didn't come (after 2 pages) until I had already started and then thank god... took over. I was convinced that I was going to be fired for failing the intubation and starting a cric on a pt I was sure was going to die. Luckily the anesthesia chief couldn't intubate either and the surgery chief finished the cric and pt lived. Other than growing some cajones, I don't find either of those experiences particularly "high yield" from a learning experience and would not wish them on any first year intern starting out. I damn near pissed myself.

 

[RPedigo]

I agree with the above two posters. Especially early in the game, supervision leads to teaching points that you otherwise wouldn't have gotten if you were truly autonomous; and intern year is a time where teaching is undoubtedly good. My first rotation of intern year was in the medical ICU where from 6p to 10a you're the only dedicated MICU physician. I got to make a lot of calls myself and got to place a lot of lines, but it wasn't until we discussed the cases in the morning that I really got to learn the finer points of the management and what I could consider doing differently next time. Autonomy is great when you know what you're doing, but front-loading your autonomy isn't likely to be helpful.

A better question is probably this: which residencies allow their senior residents to have autonomy, and which residencies have the senior residents run the emergency department. At my residency program (Harbor-UCLA), there is graded responsibility. For example, the second half of your R3 year you can start discharging patients that you worked up without speaking to an attending, if you so desire. The attendings are always there and always happy to help, but the thought is that you should have some autonomy now, while you still have the lifeline of an attending there if you need it. Other residencies that don't allow for this level of autonomy make it so your first decision that is completely and solely yours isn't until you are an attending.

That said, contrast this autonomy with the requirements of even EM residents during intern year - interns must present to a resident before presenting to an attending. This allows for two teaching sessions per patient: the resident will help you refine a plan and teach you, that plan will get put in place, and subsequently you present to the attending and learn from him or her as well. This enhances the teaching of any given subject at the relative expense of autonomy. It also enhances the resident education because now the residents have a role as an educator; they learn to teach and to guide medical students and interns, and effectively "see" twice as many patients by taking presentations and thinking about their management as well. It's a win-win situation for everyone (except that I suppose it mildly slows down the intern).

 

[docman85]

Thanks RPedigo, that's more of the response I was looking for. I am not wanting to be completely autonomous as a green intern, I was just curious to hear about other programs that were similar to the ones I've mentioned which have a more graduated responsibilty.

 

[adenocard]

My first day as an intern, I had call that night in the NSICU and had to put in a subclavian CVL that I had learned how to do that day, by myself... in an ICU full of 20+ patients where I was the only resident. 2 months later... I had to start a cric on a SICU pt who the respiratory tech dislodged the ETT during the night and pt crashed and I could not re-intubate. Anesthesia and Surgery chiefs didn't come (after 2 pages) until I had already started and then thank god... took over. I was convinced that I was going to be fired for failing the intubation and starting a cric on a pt I was sure was going to die. Luckily the anesthesia chief couldn't intubate either and the surgery chief finished the cric and pt lived. Other than growing some cajones, I don't find either of those experiences particularly "high yield" from a learning experience and would not wish them on any first year intern starting out. I damn near pissed myself.

😱

 

[deleted109597]

All residencies have graduated responsibilities. That being said, some people really seem to think the "running the department and having the lower levels check out to the upper level" thing really helps. I just say that outside of academics, this doesn't happen. The other docs working shifts never checked out to me unless they were leaving. The midlevels only came when they wanted me to basically take over the case because it was too complicated or too much work.
As an academic attending, now residents check out to me, but I never "ran the department" in residency, if only because it would be ludicrous to try and run 58 beds at a time.
I try to gauge my residents, and if they're competent, I let them do pretty much what they want. If they need help, I help them. It's what I'm here for.

 

[EMPD]

I would carefully scrutinize any program where you hear they are autonomous in their intern year. The truth is, the volumes of some places cause "autonomy" by default at times.

 

[WilcoWorld]

I don't disagree with the above posters, but be sure to make the distinction between autonomy and being allowed to see the sickest patients on day 1.

If autonomy means that you'll be working on your own and unable to find the attending for most of the shift, that's a problem.
If autonomy means that you're expected to see the sick patients on day 1, but that the attending will be standing behind you offering advice, that's a great way to train.

 

[jbar]

I think most places give you graded autonomy 1) as intern year progresses and 2) as you earn it. My first month of intern year my third year resident or the attending generally wanted to hear my plan before I started putting in orders (mainly so we don't CT scan a bunch of random people). By the middle of the year It would be expected that we were doing basic orders like labs, x-rays, giving pain meds etc without checking with anyone first. But even at the end of the first year most interns should still be talking to someone about starting patients on pressors, managing sick DKA patient's etc.

 

[VienneseWaltz]

By the middle of the year It would be expected that we were doing basic orders like labs, x-rays, giving pain meds etc without checking with anyone first. But even at the end of the first year most interns should still be talking to someone about starting patients on pressors, managing sick DKA patient's etc.

I damn well want to know in real time if someone is starting pressors--July 1 intern or June 30 senior. No matter where you are in the process, if a patient is really sick, your attending should know about it, even if he or she is going to let you run the show.

 

[deleted109597]

Yes. Critical care patients should always have the attending aware as soon as possible. Even if it's just sending a nurse or paging overhead.

 

[VienneseWaltz]

I once passed to my attending, who was tied up on the phone, a note that said, "Bed 11: Hgb 4 but it's under control." Not because I needed help, but because the attending needs to know who the sick patients are.

 

[ptarmigan]

Good attendings know who the sick patients are without any prompting.

 

[deleted109597]

Good attendings know who the sick patients are without any prompting.

Yes. I'm psychic like that. And there are never two sick patients at the same time, so I can always be bedside by the sick one.

 

[notamember82]

You've got your priorities back assward. The nurses will know more about managing patients when you start residency than you do. Autonomy is all fine and good later on in residency when you have learned the majority of your clinical medicine but you don't want it your first year. You learn by doing... but you learn from experienced mentors who have been doing EM for a looong time and have seen just about everything. Take advantage of your learning as much as you can during residency. Even when you are finishing and feel comfortable on your own managing just about anything, you'd still be a fool not to humble yourself and listen to the guys who have been doing this a LOT longer than you.

My first day as an intern, I had call that night in the NSICU and had to put in a subclavian CVL that I had learned how to do that day, by myself... in an ICU full of 20+ patients where I was the only resident. 2 months later... I had to start a cric on a SICU pt who the respiratory tech dislodged the ETT during the night and pt crashed and I could not re-intubate. Anesthesia and Surgery chiefs didn't come (after 2 pages) until I had already started and then thank god... took over. I was convinced that I was going to be fired for failing the intubation and starting a cric on a pt I was sure was going to die. Luckily the anesthesia chief couldn't intubate either and the surgery chief finished the cric and pt lived. Other than growing some cajones, I don't find either of those experiences particularly "high yield" from a learning experience and would not wish them on any first year intern starting out. I damn near pissed myself.

I just shat myself.

 

[ORL10]

I agree more with WilcoWorld. I hated the idea of graduated responsibility, meaning I had a limit to the acuity of patients I could see. I wanted to see the sickest patients on day one but have 1:1 attending coverage to help me because I had no idea what I was doing. They took over when I was in over my head, or helped me think about making tough decisions. I learned through hearing their thought process, or them forcing me to think outside of the box (i.e. "if you had to intubate this patient, and we know its going to be difficult what do we need at the bedside now, to save us time later", these are things I didn't think of in august of intern year)

This made me strong at the end of intern year, which I think is necessary for a 3 year program. By mid-third year I can run the ED. The attending sees my patients and can give tips on style points, or we can have an educated discussion about w/u in patients with varying risk factors for different diseases based on their risk threshold, but most of the time they are checking their e-mails and getting coffee.

At the same time if a patient is crashing the attending will be in the room, but I make the decision on airway, lines, resus etc...if they disagree they let me know and tell me why.

I certainly am not pushing ANYONE to CT scan, and I am definitely not putting in foley's and IV's on all patients. (urinary retention with BPH or stricture with BART kit sure...or good nurse can't get PIV I do it with US...)

Anyways, I think that system worked best for me, and med studs should figure out what works best for them. This is certainly not the "right" system for everyone, since there really is no "right" system. I will say it made for a stressful, and humbling intern year.

 

[Cerberus]

I don't disagree with the above posters, but be sure to make the distinction between autonomy and being allowed to see the sickest patients on day 1.

If autonomy means that you'll be working on your own and unable to find the attending for most of the shift, that's a problem.
If autonomy means that you're expected to see the sick patients on day 1, but that the attending will be standing behind you offering advice, that's a great way to train.

Is there really a program that lets interns see the "sickest patients on day 1"? I saw a lot of very very sick patients my intern year but the sickest (i.e pts that we are notified of in advance - arrests/resp failure) always go to the second year. I think this system works fine as you work you're way up to tge crashing patient, rather than starting with someone who is already crashing (and then just have it taken away by someone who knows what they're doing). That said, it's expected of our interns that they will be present for notifications to learn and help out.

 

[WilcoWorld]

Is there really a program that lets interns see the "sickest patients on day 1"?

Advocate Christ has this set up (at least it did last time I checked).

 

[Daiphon]

Advocate Christ has this set up (at least it did last time I checked).

Indeed.

Many programs, too, will let you have them with close upper-level and/or attending backup in the room... comes in handy when there's more than a few peeps actively trying to die.

Be assertive, but also know your limits and when to ask for help. You learn best by doing. d=)

Sent from my DROID BIONIC using Tapatalk

 

[Khaos]

Indeed.

Many programs, too, will let you have them with close upper-level and/or attending backup in the room... comes in handy when there's more than a few peeps actively trying to die.

Be assertive, but also know your limits and when to ask for help. You learn best by doing. d=)

Sent from my DROID BIONIC using Tapatalk

I was at one. My 3rd year I would routinely bring in the 2nd or 1st year...usually it would be the 2nd year to intubate and 1st year to put in the line, but many times roles were switched, and I was supervising in case someone needed help. Also, if it was a code, I ran the code and they did the procedures. The attending was sitting in the background and would only chime in if something was wrong or to make a joke. By 3rd year I had been moonlighting for over a year to a year and a half and I gave away most of my procedures to the 1st and 2nd years all the time. This happened from day 1 for the intern.

 

[jbar]

Is there really a program that lets interns see the "sickest patients on day 1"? I saw a lot of very very sick patients my intern year but the sickest (i.e pts that we are notified of in advance - arrests/resp failure) always go to the second year. t.

At Saint Luke's here in NYC the interns can have any patients, including post cardiac arrest patient. Now the 3rd year will be running the resuscitation initially, but it will go to the intern to actually write up, admit to the MICU, put in the orders, etc. I know it's not the same as running the whole thing, but that patient is considered the intern's patient. They are the one who the nurses go to for orders, who radiology is calling with the reads. (Clearly the intern is constantly touching base with the third year about the plan).

 

[Cerberus]

I was at one. My 3rd year I would routinely bring in the 2nd or 1st year...usually it would be the 2nd year to intubate and 1st year to put in the line, but many times roles were switched, and I was supervising in case someone needed help. Also, if it was a code, I ran the code and they did the procedures. The attending was sitting in the background and would only chime in if something was wrong or to make a joke. By 3rd year I had been moonlighting for over a year to a year and a half and I gave away most of my procedures to the 1st and 2nd years all the time. This happened from day 1 for the intern.

Well, this is similar to my program (although it's the second year running the show and calling the shot - while being supervised by 3rd yr and/or attending). Our interns get plenty of procedures if they help out and are present for resuscitations. I think this is different than "seeing the sickest" patients though as they may be involved but they are not owning the patient.

 

[Rendar5]

Well, this is similar to my program (although it's the second year running the show and calling the shot - while being supervised by 3rd yr and/or attending). Our interns get plenty of procedures if they help out and are present for resuscitations. I think this is different than "seeing the sickest" patients though as they may be involved but they are not owning the patient.

My program had a "graduated responsibility" format of interns not being in the critical care area alone (meaning they're allowed to have day shifts there when there's a second resident on, but no night shifts until the end of the year). So sure they'll see the sickest patients day 1, but they won't ever be alone seeing them. And there will be someone more senior when procedures need a more senior person.