what does 'autonomy' really mean?

[anatomyaddict]

hey guys,
did an away rotation at a very academic school- I keep hearing that at academic institutes while you get access to amazing research and fellowship opportunities you often compromise the strength of your training due to loss of autonomy

i've been trying to keep track of this. General clinic protocol that I saw is: the resident goes in, sees patient. Then attending goes in, sees patient- resident may or may not be with them. Resident and attending discuss patient afterwards, put attending does not ask resident for a treatment plan or anything of that sort.

As for surgery, there is increasing responsibility every year of residency

so I guess my question is, what exactly does autonomy mean in the context of an ophtho residency in terms of clinic and surgery? what should we be looking for in programs when we go on interviews?

I want to do a fellowship but I also want a solid general ophtho background for international medicine, so I'm trying to find that balance I suppose.

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[90 diopter]

I trained at a program that is about as autonomous as it can possibly get without breaking any laws.

Resident brings patient in, performs exam, comes up with treatment plan, and sends patient home. Chart goes in a pile which later gets reviewed and signed off by attending. If any major (or even minor) errors are noted, attending berates resident (in a firm yet comical way) and resident learns not to make the same mistake next time. For complex patients, resident enlists help of 2nd or 3rd year resident. For disaster patients, attending examines patient with resident. Surgeries are always supervised. After doing this 12 hours a day for 3 years, transitioning into private practice is easy.

As you can imagine, things occasionally fall through the cracks with such a system. But it teaches you independence early on and forces you to make your own decisions, even as a first year resident. In my opinion, there is no better way to learn.

 

[Visionary]

I trained at a program that is about as autonomous as it can possibly get without breaking any laws.

Resident brings patient in, performs exam, comes up with treatment plan, and sends patient home. Chart goes in a pile which later gets reviewed and signed off by attending. If any major (or even minor) errors are noted, attending berates resident (in a firm yet comical way) and resident learns not to make the same mistake next time. For complex patients, resident enlists help of 2nd or 3rd year resident. For disaster patients, attending examines patient with resident. Surgeries are always supervised. After doing this 12 hours a day for 3 years, transitioning into private practice is easy.

As you can imagine, things occasionally fall through the cracks with such a system. But it teaches you independence early on and forces you to make your own decisions, even as a first year resident. In my opinion, there is no better way to learn.

Pretty sure that's not legal anymore. An attending is supposed to at least lay eyes on every patient a resident sees, unless it's an overnight call patient.

It does speak to the OPs question, however. The more "autonomous" programs have more direct resident involvement in the exam, diagnosis, and plan. The attending can always override, though. The less "autonomous" programs involve a lot more shadowing of attendings in their clinics. This is often held up as a criticism of the top tier programs, where patients go to see a big wig doc, not a resident or fellow. I'd say that actually varies. I know of multiple top tier programs that are very "autonomous," in addition to having great faculty and strong research.

 

[Meibomian SxN]

....Resident brings patient in, performs exam, comes up with treatment plan, and sends patient home. Chart goes in a pile which later gets reviewed and signed off by attending. If any major (or even minor) errors are noted, attending berates resident (in a firm yet comical way) and resident learns not to make the same mistake next time.....As you can imagine, things occasionally fall through the cracks with such a system.

Sounds like excellent care to me. I'm sure no one EVER slips through the "12,000hr resident's learning foundation" right?.....

 

[MullerCell]

I think that a blend of autonomy and supervision is key. I think the best setup is to have a main eye institute where residents work closely with faculty in sub-specialty clinics with faculty seeing every patient after the resident and critiquing the exam, assessment/plan and then also having a VA and county hospital where they rotate and experience gradual autonomy with supervision in clinic (with staff reviewing every patient note, but not seeing every patient) and always having staff present in the OR. As a resident, I really felt I could handle anything by the time I was a 3rd year. Then I went and did a 2 year VR surgery fellowship at a different institution and realized how much more there was to learn.

 

[MR1]

Agree, a good blend is necessary. If you are always on your own then how do you learn. The best programs have a combo of this.

For example, I loved my residency because at the University we had resident clinics where although you were staffed and the attending saw the patient, YOU had to come up with the plan (unless you were out in left field of course). Then the attending clinics where you saw everyone and discussed later with the attending the plan. Finally the good ole VA (or community clinic elsewhere) where there was staff available if you needed them but you were the doctor and if you needed help 90% of the time it was upper level residents, only about 10% of the time did you recruit staff.

As far as OR, you never want to be operating by yourself. Now that doesn't mean have to have them scrubbed. I liked that my attendings towards the end didn't scrub and sometimes showed up late. It pushes you to get comfortable.

The main thing to ask the PGY4's is how comfortable they are, both clinically and surgically. If they are not very comfortable that is not a good sign.

 

[90 diopter]

Sounds like excellent care to me. I'm sure no one EVER slips through the "12,000hr resident's learning foundation" right?.....

Many patients slip through the cracks. Everyone makes mistakes, and it's a part of training. Considering I went to a perennial top 10 program where our graduates get pretty much whatever fellowship position they want (for those who choose to specialize), I'd say my foundation is pretty solid.

After 3 years of making tough decisions on some of the worst eye pathology in the United States, transitioning into private practice was a joke- there is nothing I've seen in my practice that has rattled me even a little bit. And I wouldn't want it any other way.

 

[200UL]

As said above - I believe balance is needed. There are different ways to allow transition to private practice. Plain and simple - seeing as many complex patients in every subspecialty and doing lots of surgeries from every subspecialty is the way to do this. In my opinion success can be obtained with a lot of autonomy or little autonomy. However, in the OR setting, I strongly feel it is best having someone very experienced assisting a resident. I still remember all the points my attendings made in the heat of battle. I am dependent on this pearls today.

Regarding what is legal these days in ophthalmology- if a program wants to bill Medicare or 3rd party payer, a fellow or staff doctor must see the patient (or it is not legal). The days staff "signing off" on these patients at the end of the day are long over (the VA system has exceptions for this/ county hospital systems may also have exceptions (then again perhaps billing for these patients is a moot point in some locations as no revenue will ever be gained - therefore who cares if you bill - just take care of the patient).

Finally, Meibomian SxN - don't rip on 90 diopter's training experience. He saw more pathology in one afternoon in his training program than you saw in your entire training program. The point of this thread is that experience matters.

 

[VikingFavre]

Real autonomy is when by the 3rd month of residency you are doing multiple PRP and focal lasers, intravitreal injections daily, and running your own diabetic retinopathy clinic solo. Ideally it's nice to be at a place where if you need help it's always there but you only get it if you ask for it.

 

[Visionary]

Real autonomy is when by the 3rd month of residency you are doing multiple PRP and focal lasers, intravitreal injections daily, and running your own diabetic retinopathy clinic solo. Ideally it's nice to be at a place where if you need help it's always there but you only get it if you ask for it.

No, that is more like insanity than autonomy. 😱

 

[dantt]

I rotated at a program where the vast majority of patients never saw an attending or fellow. The only ones who saw attending/fellows were highly complicated cases that were rescheduled to subspecialty clinics. Many surgeries even occurred without staff supervision present and observing...

Pretty sure that's not legal anymore. An attending is supposed to at least lay eyes on every patient a resident sees, unless it's an overnight call patient.

It does speak to the OPs question, however. The more "autonomous" programs have more direct resident involvement in the exam, diagnosis, and plan. The attending can always override, though. The less "autonomous" programs involve a lot more shadowing of attendings in their clinics. This is often held up as a criticism of the top tier programs, where patients go to see a big wig doc, not a resident or fellow. I'd say that actually varies. I know of multiple top tier programs that are very "autonomous," in addition to having great faculty and strong research.

 

[VikingFavre]

No, that is more like insanity than autonomy. 😱

Why do you think so? Anything can become the norm and routine with practice.

 

[MstaKing10]

I think a graded approach, where early on in training you are supervised but later on in training you are allowed to fly more solo makes more sense to me. Doing a lot on your own in the first year of residency likely means you are missing a lot of subtle findings on exam, mismanaging patients in clinic, and doing procedures incorrectly. Certainly during the later portions of your third year you should feel comfortable examining and treating patients and performing procedures on your own and be allowed to do so. As stated elsewhere, a balanced approach is the most reasonable. That said, certain personality types may flourish in a program more tilted to either extreme.

 

[Visionary]

Why do you think so? Anything can become the norm and routine with practice.

Because no 1st year resident in the 3rd month of training should be diagnosing/treating patients without supervision, let alone running their own clinic. I don't care where you train. There is no way you learn enough in 3 months to run anything, especially a diabetic eye clinic. Residency is not supposed to be a self-study course. These are patients, not lab rats.

 

[Visionary]

I rotated at a program where the vast majority of patients never saw an attending or fellow. The only ones who saw attending/fellows were highly complicated cases that were rescheduled to subspecialty clinics. Many surgeries even occurred without staff supervision present and observing...

That's definitely illegal . . . and scary. I'll wager that's a program that will be on probation soon.

 

[MR1]

Real autonomy is when by the 3rd month of residency you are doing multiple PRP and focal lasers, intravitreal injections daily, and running your own diabetic retinopathy clinic solo. Ideally it's nice to be at a place where if you need help it's always there but you only get it if you ask for it.

I rotated at a program where the vast majority of patients never saw an attending or fellow. The only ones who saw attending/fellows were highly complicated cases that were rescheduled to subspecialty clinics. Many surgeries even occurred without staff supervision present and observing...

Agree, either this is BS or extremely scary
No PGY2, 3mths into a rotation should be "running" a clinic. Maybe, maybe doing injections or PRP.

The second one is not as scary for clinic but definitely surgery. Every surgery needs\has to be staffed for both our education and patient safety.

 

[dantt]

Agree, either this is BS or extremely scary
No PGY2, 3mths into a rotation should be "running" a clinic. Maybe, maybe doing injections or PRP.

The second one is not as scary for clinic but definitely surgery. Every surgery needs\has to be staffed for both our education and patient safety.

I guess it depends on the definition of staffed; available vs. present and scrubbed.