What's your patient load?

[readdoc]

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Intern year -- doing IM rotation. Handling a lot of patients. Wondered how many patients other interns see daily. Responsible for five? For ten? For more?

 

[POW16]

Anesthesia PGY-2 here but rotated in IM on the wards last year. Up to 10, probably averaged around 6.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[link2swim06]

On floor or ICU?

 

[MLT2MT2DO]

Psych intern, on IM in the hospital avg about 6 only hit 10 a couple times. During VA IM month avg like 3, best month of intern year so far.

 

[Raryn]

Intern year -- doing IM rotation. Handling a lot of patients. Wondered how many patients other interns see daily. Responsible for five? For ten? For more?

ACGME limit is 10. Programs can set lower caps... the lowest I've seen a cap is 7 at some of the Kaiser programs.

At my program, for wards, we set it at 10. Outside of the occasional post-call or weekend day, our interns rarely get to 10. Averaging the various days in the call cycle our interns usually see 7, up to 8-9 on a typical post-call day, down to 3-4 on a precall day.

For ICU, the cap is also technically 10, but we try to limit our interns to no more than 6-7. Our PD says we'd ideally limit our interns in the MICU to 5, but that's rarely possible. Sometimes in the winter we break our unofficial limit of 6-7, but even then, even on a weekend day in the winter, I've never given an intern 10 patients in the unit.

 

[readdoc]

My question was about on the floor. I'm seeing about 10 for the last few weekdays and feel like I'm almost giving substandard care because there's so much **** to do. Just wondered if others felt the same. I always want to feel like I'm doing my best for the patients, but I'm feeling slammed.

 

[Gfliptastic]

I'm in Gen Med/Floor hell, and mostly have been so far. We cap at 15. We are 2 interns, 1 resident, 1 attending. So we usually carry 7 or 8. We don't run around capped all the time though. So 6 is fairly normal. 5 is cake. 4 is barely worth getting out of bed for lol (But you have time to run to the caf to eat breakfast before rounds). 3 is what we usually let our med students follow.

Our cardiac floor teams cap at 12. 1 intern, 1 resident, 1 attending. So...when your resident has either the day off or clinic, you carry 12.

 

[WinslowPringle]

Current rotation worst was 25 floor patients and 5 ICU patients. Some were consults, some were simple post-op day one or obs, but not most. Still a lot of rounding. Currently the rotation is lighter because of the holidays, so am rounding on 12. Average is 15-20.

I hate discharge summaries.

Average census for most rotations is ~10. Trauma can get super crazy, though.

Edit: Sorry, general surgery, not internal medicine. *Shudder* 10 MICU patients as an intern would be a nightmare!

 

[Crayola227]

I'm in Gen Med/Floor hell, and mostly have been so far. We cap at 15. We are 2 interns, 1 resident, 1 attending. So we usually carry 7 or 8. We don't run around capped all the time though. So 6 is fairly normal. 5 is cake. 4 is barely worth getting out of bed for lol (But you have time to run to the caf to eat breakfast before rounds). 3 is what we usually let our med students follow.

Our cardiac floor teams cap at 12. 1 intern, 1 resident, 1 attending. So...when your resident has either the day off or clinic, you carry 12.

Odd... my program had the 1 resident 1 intern team capped at 10 just for the reason that when the resident has day off then intern has the census... I could be wrong but that sounds like an ACGME violation for IM

I would doublecheck. I always say don't make waves but don't let your program violate the ACGME rules... that's one instance where you're looking out for everyone involved

and by the way anything besides the 1 resident 1 intern 10 patients arrangement sounds waaaaaaaaay better. Nothing like having 10 patients to yourself day in day out your second month of internship... and then when the senior's away.... yuck. Yuck. One senior I had carried the med student patients and the other didn't.

Some programs and some seniors think the med student is the intern's responsibility and others think it's the seniors. I think it should be the seniors, a two-month intern with 10 patients daily has 0 time for teaching.

 

[Crayola227]

Current rotation worst was 25 floor patients and 5 ICU patients. Some were consults, some were simple post-op day one or obs, but not most. Still a lot of rounding. Currently the rotation is lighter because of the holidays, so am rounding on 12. Average is 15-20.

I hate discharge summaries.

Average census for most rotations is ~10. Trauma can get super crazy, though.

Edit: Sorry, general surgery, not internal medicine. *Shudder* 10 MICU patients as an intern would be a nightmare!

Yeah the most I had was 7 and it was 2 weeks into internship... and like only 2 were mine, the other 5 were either new or a fellow intern's I was covering. That was not a good day.

 

[Crayola227]

Does anyone know what the rules are when other specialties rotate through an IM rotation at a place that has an IM program in place?

I would assume if there's an IM residency in place that the rotating intern/resident from another specialty would be subject to the same rules.... the rules the ACGME (or is the ABIM that has the cap rules?) lays out for an accredited IM residency program I would think would just be universal, plus it seems like it would be too much work to change/keep track of different rules different residents and that an IM program would just keep everything status quo as far as rules on caps so as to avoid the bad side of ACGME/ABIM/whoever, but that's just my opinion of how I would *think* or *like* it to be, I have no idea. What do you guys think/know?

 

[mvenus929]

Does anyone know what the rules are when other specialties rotate through an IM rotation at a place that has an IM program in place?

I would assume if there's an IM residency in place that the rotating intern/resident from another specialty would be subject to the same rules.... the rules the ACGME (or is the ABIM that has the cap rules?) lays out for an accredited IM residency program I would think would just be universal, plus it seems like it would be too much work to change/keep track of different rules different residents and that an IM program would just keep everything status quo as far as rules on caps so as to avoid the bad side of ACGME/ABIM/whoever, but that's just my opinion of how I would *think* or *like* it to be, I have no idea. What do you guys think/know?

If the rotating resident is on an IM service, I think they have to comply with IM rules. When we have FM residents rotate with us, if they break duty hours, our program gets dinged.

The caps are specific to IM, though. Our interns don't regularly go over 7 or so patients, except in the NICU (usually 6-9 patients at a time), level 2 (I've seen up to 18 patients each there), and newborn nursery (I've rounded on 20 as an intern). But babies tend to be less complicated than other patients. Every so often, especially on weekends or holidays, the interns will round on 10-11 on wards, but it's relatively rare.

 

[Crayola227]

If the rotating resident is on an IM service, I think they have to comply with IM rules. When we have FM residents rotate with us, if they break duty hours, our program gets dinged.

The caps are specific to IM, though. Our interns don't regularly go over 7 or so patients, except in the NICU (usually 6-9 patients at a time), level 2 (I've seen up to 18 patients each there), and newborn nursery (I've rounded on 20 as an intern). But babies tend to be less complicated than other patients. Every so often, especially on weekends or holidays, the interns will round on 10-11 on wards, but it's relatively rare.

yeah, it never ceases to amaze me, especially how much Peds residents here complain about being micromanaged, how you guys don't seem to have caps! I looked up the peds rules once can't remember specifically except that it didn't seem as strict/spelled out as for IM

 

[rokshana]

Odd... my program had the 1 resident 1 intern team capped at 10 just for the reason that when the resident has day off then intern has the census... I could be wrong but that sounds like an ACGME violation for IM

I would doublecheck. I always say don't make waves but don't let your program violate the ACGME rules... that's one instance where you're looking out for everyone involved

and by the way anything besides the 1 resident 1 intern 10 patients arrangement sounds waaaaaaaaay better. Nothing like having 10 patients to yourself day in day out your second month of internship... and then when the senior's away.... yuck. Yuck. One senior I had carried the med student patients and the other didn't.

Some programs and some seniors think the med student is the intern's responsibility and others think it's the seniors. I think it should be the seniors, a two-month intern with 10 patients daily has 0 time for teaching.

sorry...but the 1 resident 1 intern cap is 14 per ACGME guidelines...

and 3rd years are the responsibility of the intern...teaching is part of the job as an intern as well as the resident...the sub i is the responsibility of the resident.

 

[Raryn]

Odd... my program had the 1 resident 1 intern team capped at 10 just for the reason that when the resident has day off then intern has the census... I could be wrong but that sounds like an ACGME violation for IM

I would doublecheck. I always say don't make waves but don't let your program violate the ACGME rules... that's one instance where you're looking out for everyone involved

and by the way anything besides the 1 resident 1 intern 10 patients arrangement sounds waaaaaaaaay better. Nothing like having 10 patients to yourself day in day out your second month of internship... and then when the senior's away.... yuck. Yuck. One senior I had carried the med student patients and the other didn't.

Some programs and some seniors think the med student is the intern's responsibility and others think it's the seniors. I think it should be the seniors, a two-month intern with 10 patients daily has 0 time for teaching.

The ACGME cap for a 1 resident 1 intern team is 14.

https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf

See section I.A.2.h).(6).(e)

Also, the M3 students *are* the interns responsibility in addition to all members of the team being the seniors responsibility. M3's patients are carried with the intern and the intern should go over their patients with them. The senior is there for oversight/feedback of them both, and the attending is there for oversight of everyone.

M4 students on an IM wards service on the otherhand should work directly with the senior resident and shouldn't be expected to run things through interns. They're "acting interns" after all.

Some of my coresidents are lazy and try to pawn off the M4s patients onto interns b/c they don't want to write notes anymore, but most of us know that's inappropriate. I write full progress notes for all the patients my M4s see.

 

[mvenus929]

yeah, it never ceases to amaze me, especially how much Peds residents here complain about being micromanaged, how you guys don't seem to have caps! I looked up the peds rules once can't remember specifically except that it didn't seem as strict/spelled out as for IM

There are no ACGME mandated caps for Peds. A lot of programs institute a cap of 10 wards patients for the interns, but mine chooses not to. Not sure why the culture is different, perhaps it's because of the nursery aspect of our training. Or because stand alone hospitals, which tend to be those programs without caps, rely on the residents more than an IM program with a separate Hospitalist service that patients can be shunted to.

 

[j4pac]

There are no ACGME mandated caps for Peds. A lot of programs institute a cap of 10 wards patients for the interns, but mine chooses not to. Not sure why the culture is different, perhaps it's because of the nursery aspect of our training. Or because stand alone hospitals, which tend to be those programs without caps, rely on the residents more than an IM program with a separate Hospitalist service that patients can be shunted to.

Money.

 

[rokshana]

There are no ACGME mandated caps for Peds. A lot of programs institute a cap of 10 wards patients for the interns, but mine chooses not to. Not sure why the culture is different, perhaps it's because of the nursery aspect of our training. Or because stand alone hospitals, which tend to be those programs without caps, rely on the residents more than an IM program with a separate Hospitalist service that patients can be shunted to.

i think there is ore attending involvement with peds residents than with IM residents...or maybe generally kids are not that complex (meaning they don't have al the crazy comorbidities that adults do)...though frankly they scare me 🙂

 

[gapeach06]

I think there is only a cap for IM. I'm interviewing for Psychiatry and most of the programs I've gone to have said that they typically see way more than 10 pts a day for interns.

 

[Gfliptastic]

The ACGME cap for a 1 resident 1 intern team is 14.

https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf

See section I.A.2.h).(6).(e)

Also, the M3 students *are* the interns responsibility in addition to all members of the team being the seniors responsibility. M3's patients are carried with the intern and the intern should go over their patients with them. The senior is there for oversight/feedback of them both, and the attending is there for oversight of everyone.

M4 students on an IM wards service on the otherhand should work directly with the senior resident and shouldn't be expected to run things through interns. They're "acting interns" after all.

Some of my coresidents are lazy and try to pawn off the M4s patients onto interns b/c they don't want to write notes anymore, but most of us know that's inappropriate. I write full progress notes for all the patients my M4s see.

Where I did IM as a med student was very much like that. Glad to know it was rooted in something, not something arbitrarily made up by the hospital LOL.

And yes our M4/sub-I's go thru the seniors. We do get the M3's. And our rounds let the M3's present to the attending as kind of a back check to what we teach the M3's. We mostly confirm what we ordered that was in agreement w/ our M3's "not for billing purposes" note.

I would hope my IM program was in accordance w/ ACGME, but it REALLY sucks when you do have 12 CCU pts and 2-3 of them are fairly ill. Adding 2 more to when I did have to carry 12 on CCU just reeks of s*** show for your average PGY1!!

 

[Crayola227]

sorry...but the 1 resident 1 intern cap is 14 per ACGME guidelines...

and 3rd years are the responsibility of the intern...teaching is part of the job as an intern as well as the resident...the sub i is the responsibility of the resident.

ah thank you for the clarification on cap

you can't make a blanket statement which student goes to which type of resident for teaching, that is very institution specific
I can say that as I interviewed at 30+ programs and very interested in teaching and literally one of my questions and checkboxes for comparing programs was "who has primary responsibility for medical student education on the team" and how residents were involved so I can tell you from that experience many programs had VERY firm strong feelings on who went to who and did what that could differ widely

one PD looked at me like I had a 3rd head for suggesting that the intern would ever be involved in teaching medical students of any type (weird program)
some programs I knew none of the residents formally eval'd the students at all
some programs it was only the intern not writing evals of any sort, which is sort of odd to me if they have primary responsibility over MS3

I never meant to say that interns should not be responsible for teaching.... I guess I wasn't clear, as an intern 1-2 months in I was given basically total responsibility for the subI, I did the best I could but feel pretty bad about the quality of education I think they got from that
they probably got less medicine and more scut education which has its own value you can say

I tried to cheer them up that as a month 2 intern vs the senior I had closer perspective on "this is what I really wish I had known day 1 of internship" "and what I wish I had learned 4th year"

personally I feel my med student education really suffered being dumped on the intern for everything at all stages

 

[Crayola227]

i think there is ore attending involvement with peds residents than with IM residents...or maybe generally kids are not that complex (meaning they don't have al the crazy comorbidities that adults do)...though frankly they scare me 🙂

I dunno I raised that idea with my best friend in Peds who said at least on the inpatient side that since kids are typically healthy it's usually like a multi-hit scenario to get them sick enough for hospitalization for any real length of time, a lot of their "gorked" kids make our super sick "gomers" look like a cakewalk.

And that while kids compensate so well, that means that when they decompensate it's usually fast and scary.

And like any hospitalized cohort, you have your simple in-&-outs for one big thing and your super comorbid frequent flyers. I wonder tho if the ratio of simple to really sick is different so not having caps just lets the peds residents have a larger number of 1-issue kids in addition to the core gorked.

Yeah I talked with that friend about caps tho and their impression was that there is so much oversight built in at every level that was the jusitification no caps peds vs IM.

I'm with you there that the sick kids they describe make me shudder... they always sound so much sicker than my sickest... and let's be honest, my comparable 80 yr old gomer it's just not as tragic when they succumb as when a kid dies.


TLDR
kids decompensate fast when they do and the gorked are often as bad as the gomers per comparing notes with my Peds friend
impression was just that there's a lot of oversight and doublechecking and hovering attendings that is why no caps

 

[mvenus929]

And like any hospitalized cohort, you have your simple in-&-outs for one big thing and your super comorbid frequent flyers. I wonder tho if the ratio of simple to really sick is different so not having caps just lets the peds residents have a larger number of 1-issue kids in addition to the core gorked.

I'd rather have 5 kids on the subspecialty teams that are super complicated but are there for an extended period of time than 6-7 RSV bronchiolitis infants that are basically the same patient. The turnover on our hospitalist team is what makes that team so challenging, not the difficulty of the patients themselves. When you get 2-3 new kids every morning and discharge half of your kids by the end of rounds, there's a lot of paperwork involved that is difficult to keep up with.

 

[Mass Effect]

I'm psych, but when I was an intern and had to do my IM months, we were capped at 10 per intern and each team had 2 interns and one senior. So our team cap was 20. To whoever asked, ACGME rules state that each intern is capped at 10, so if a team has two interns, they can cap at 20 and we were FREQUENTLY capped. I think there were only 4-5 days that my personal census fell below 10. Our team census never fell below 15.