That's what I was hinting at
Is that actually something that most of medicine did?
I'll start with you can never really compare any place to Kaiser and Geisinger they are willing and able to try any and everything that they can be more efficient for their members + employees + bottom line. With that said I have seen practices that are trying to have physicians take the majority of the "difficult" patients and APPs take everything "easy" the big push back we hear to this is that leads to crazy high physician burn out. On the specialty side, triage function or capability is becoming more and more common to the point that I think there will be a time that if you aren't 95%+ an operative patient you won't see a surgeon. Let me know if that answers your general question.
There are not a surplus of "experienced attendings" physicians available at night. At my last place, there was a team composed of an anesthesia attending and 2-3 PA/NPs who were experienced. If the primary floor nurse felt a patient needed immediate MD attention she would call the aforementioned response team. The resident team was to report to bedside if it was their patient to facilitate care.
This post is 100% truth that some SDN medical students may try to refute while in reality this is the vantage point medical students need to have. Bolded are 100% true and I can confirm with examples (if needed). @Lem0nz basically summarized the crux of why we graduate incompetent physicians. Half of IM are truly checked out for fellowship (where they feel like their learning really is) and act like glorified scribes (albeit know generally who to refer to or call if stuff goes downhill which works because they're working at a quaternary referral center). Also completely agree that RWJ in particular has a very weak/soft-whatever you want to call it (minimal call) residency but this isn't unique to them for sure and instead spend time with MKSAP in the morning rounds. There are several residencies in the so-called upper tier IM weight class that function very similarly so its not just them.
Lawps, I'm sorry to say this is one of the truest posts I've seen on SDN. Page 3 of this thread is basically a string of epic truth bombs.
Was it not the AMA that lobbied for a cap on residency positions in the 90s because they feared oversaturation?
Every physician should at least have 1st level necromancy spells in their arsenal
...and to tie this back into the midlevel discussion, this is why midlevels are empowered to do so much more because they have such a narrow scope. At my last place, there was a midlevel who did nothing but be part of the rapid response team and was called specifically only when there was suspected respiratory failure. Emergent respiratory issues is all he's been doing for the last 5 years. He knew everything about the signs, P/F ratios, etc. and knew exactly when to call/transfer to the MICU. There isn't really a dedicated time where this is formally taught/assessed with any validity in a standardized way in IM residency and hence some residents learn it, but a large amount skate by knowing enough to fake it while in reality allowing others to handle it. Heck, even some pulm/crit care aspirants skate by and probably get exposed in fellowship.
You can't.
Wait are you a resident?! I have read probably a couple thousand of your posts and can't remember if you're just really passionate about med ed topics or a physician or something.
Your contributions are appreciated. A medical student?Nah i'm just a dumb student who spends way too much time on SDN
Yeah
Future IM applicants, this comment is gold. On the interview trail, there were indeed highly ranked programs that you'd probably salivate at getting into, particularly a number of the "clinics", but you may not get the same autonomy to become a truly independent physician. I remember interviewing at one of these "clinics" and a resident admitted to me that 80% of the patients come in with an established specialist on board or with workup done from an affiliate hospital and your job as the medicine intern is to put in whatever orders said specialist wanted you to put in. You get very little ownership of your patients. Sure the fellowship results look beautiful, but you really have to evaluate what you truly want. Do you want to be a better doctor or ivory tower socialite? No wrong answer here, but ya'll can probably see my preference.
People just want to get into their desired fellowship. So it’s either push yourself and work harder at a large low tier tertiary care community program, have less time to publish and schmooze all the while boxing you out of the best fellowships; or go to the big name program that treats you like this but basically guarantees you get to pursue your desired career goals.
Like I said, there's no wrong choice here. Honestly, it's more of an x and y axis when you look at rigor and prestige. You can have both. It's important to parse it out on the interview trail and think carefully about your priorities.
I feel like the knowledge of critical care helps for fellowships (talking outside of pulm) but idk. Maybe not.
No doubt it also helps you be a competent doctor which is the whole point of being there. This actually infuriates me that residents are allowed to do this and make us all look the stereotypical lazy/arrogant/incompetent doctors that midlevels always say that we are. I’d heard about this but always assumed it was just people talking out of their butts. I’m just a lowly osteopathic sorcerer, so my training has been in community programs. And a resident not taking ownership of their actively coding patient wouldn’t be a resident much longer.
No i get it. Thanks, i appreciate your thoughts.
Thanks, this is a bit reassuring
I’m going into IM. And I want to do primary care. I will do (and have done) the best I can on my ICU rotations. And I will (and have) gone to any rapids and codes for *my* floor patients. But expecting every IM resident to be excited to drop everything to run to every code in the hospital for any patient in the middle of rounds, didactics, calling families, writing notes, doing admits, following up after labs/procedures, checking on patients, checking in with the attending, etc and starting throwing in lines like a cowboy is unreasonable. Not to mention does *not* accurately reflect the workflow of any attending physician, as pointed out earlier.
Physicians are held to Physician standard
I have no idea. Got a source that shows that?
I have no doubt you will give it your all and be a superstar IM resident and many end up learning the critical emergent/resuscitation skills. As you're about to be an intern in 2-3 months, you'll obviously know you're required to drop everything be at code blues/rapid responses on your patients but then the question becomes what is your immediate role on your team. At many places, if someone else comes in really quick and does it all for you without much teaching and you're left to essentially document that makes it difficult for you to really learn. Rounds, calling families, writing notes, *ordering* labs/procedures, checking on patients, checking in with the attending (also CM rounds/signing out/hearing report on new patients) are basically your tasks for the day and you can do well without really developing much of a medical acumen for diagnosis or treatment. Plans are oftentimes outlined for you. What diagnostics to order and what treatments to do can be a useful discussion with attendings if they're open to actual discussions which many are but eventually it may come down to what "they want". The key is really if you're the one primarily driving the plans AND if the attending is knowledgeable enough to let you do what's right but also be attentive enough to detail and medically sound enough to catch errors in your process AND be patient enough to explain them to you in a non-demeaning way (so that the game doesn't become avoiding discussion with that attending again). That is what will help you learn. Many places have that in place, many don't. I don't necessarily think it is fully revealed on the interview trail but I think extreme cases are often mentioned on the interview trail.
This is a very underrated point of this conversation. I'm in disbelief I don't see it articulated much more. It seems to be in the US profits really do drive all decisions (yay market forces!) including all decisions in healthcare. It shouldn't be controversial to say that our populous deserves the highest level of care from the highest level of medical education which includes medical school + residency/fellowship training and proper board certification.
Sorry to derail the post. The last two codes I went to at my hospital as med students. The codes were ran by PGY2, no faculty supervision/fellow. The first one was messy. Tube which was placed by anesthesia resident was in his stomach for good 10 mins at least until they noticed the abdomen was getting inflated. Patient died. The second one was pretty good I though but an ED fellow stepped in. If not, it would have been a pgy 2 who was 4-5 months into PGY2 year.
It becomes a slippery slope. If you don't want a resident to run a code, then you can gradually push that further: I don't want a resident doing my "x" procedure. We're then raising a weaker generation of physicians.
I have never seen a resident run a code in a pediatric hospital (except maybe initially for the first minutes or so till help arrives). This has more or less been the standard since I've been in training starting 15 years ago.
A different topic and not relevant to pediatric codes or procedures... but the pediatric hospitalist fellowship is mostly a farce that really wasn't thought out clearly and doesn't really have any clear goals other than increasing the duration of training cause reasons. But I digress.
Could this be the variation in IM program quality? Because this isn't matching with Lem0nz's experience.
This is absurdly depressing to hear as someone who wants to do IM/Peds.
Huh, learn something new every day.Doctors Assert There Are Too Many of Them (Published 1997)
American Medical Assn and reprs of nation's medical schools say that United States is training far too many doctors and that number should be cut at least 20 per cent; orgns caution that US is 'on the verge of a serious oversupply of physicians'; warn that current rate of physician...www.nytimes.com
I thought this was fairly well known history? Basically the AAMC and AMA pushed for caps on residency positions due to a feared physician oversupply situation
I went to a high volume community surgery residency that was great quality. I don’t know what other community IM residencies are like, but the one at our hospital was very weak. The one at my current fellowship is also very weak. I don’t know if this generalizes to many community programs or if I just got two bad batches. I will say some of my friends and smartest people I met in residency *were* in that IM program. They were just the minority. They also did exceptionally well, went on to match heme/onc or interventional GI, and tolerated no laziness or shortcuts in their own training, their resident duties, or being a doctor in general regardless of their level of interest in a particular field. I believe some of this mentality was that they had no idea what they may end up doing because matching to competitive fellowships from there was never a guarantee, so everything was important to learn and you may be practicing anything/everything once you’re out in the wild. That was absolutely my mentality in my own general surgery training and still is. I hate vascular, but gods dammit, if I end up someplace and end up doing it I better sure AF not suck at it.
Thanks. Sorry for jumping into incorrect conclusions. There's a lot for me to learn and experience (especially since i'm just a measly dumb student), but i'm taking these posts if only for personal improvement as a way to strive to be greatest future resident/physician i can be.
Does it make me a weaker future PCP to not throw 50 central lines in?? Because if that’s what you’re saying I fundamentally disagree.
