Which setting is best for primary care experience in 1st year?

[masterofmonkeys]

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I'm in my 5th of 12 ward months now as an intern (lol). And I can't help but wonder if 4 months of inpatient medicine/peds is the best use of our training time.

I actually enjoy inpatient medicine quite a bit...when it's not in a sweatshop environment. Same for peds. I prefer the pace in a lot of ways. But i can't help but thinking back to my third year, when I aced inpatient medicine, but was so confused in outpatient medicine it wasn't even funny. "you want me to look in his throat? Sinusitis? Allergies? Asthma? I have no idea what the heck is going on!!!"

It seems to me that while being medically competent is good (as attested to by the numerous hypertensive urgencies, handful of minor CHF exacerbations, and even one case of mild hemorrhagic shock I've already had to handle), patients on a psych floor are--theoretically at least-- medically stable and do not have any medical issues that warrant inpatient hospitalization. The medical issues we are far more likely to encounter in practice are indeed those things best handled in an outpatient setting.

Seems to me that things like ER, urgent care, and more outpatient experience would thus be in our best interest to pursue in our intern years. I'm not saying 'no inpatient experience' because it's pretty hard to be good at c/l (which is a strong possibility for me personally) without that kind of experience and familiarity. But I'd think experience in ER and urgent care would be highly beneficial to us educationally.

More pragmatically, a lot of medicine programs rely on interns rotating through the wards as nothing more than slave labor, with minimal added educational value. It seems like the ability to say 'fix it or we're taking our interns and sticking them in the ED' would be a good way to put pressure on these medicine programs not to abuse these rotating interns.

And when I say abuse, I'm not necessarily talking about hours. On inpatient peds I'm working darn near the work hour limit, but actually having a pretty good time and an edifying experience...at one of the top peds hospitals in the country. The medicine experience...isn't quite so good here.

Thoughts?

 

[michaelrack]

"Seems to me that things like ER, urgent care, and more outpatient experience would thus be in our best interest to pursue in our intern years."

I agree

"a lot of medicine programs rely on interns rotating through the wards as nothing more than slave labor, with minimal added educational value."

I agree

"It seems like the ability to say 'fix it or we're taking our interns and sticking them in the ED' would be a good way to put pressure on these medicine programs not to abuse these rotating interns."

Most psych residency programs lack the power and interest to do this.

 

[Doctor Bagel]

I know some programs do half inpatient and half outpatient for your 4 months of primary care, but they do seem to be the minority. Personally I've done a ton of work at our free clinic, so I'm pretty comfortable with outpatient medicine and think I'd actually gain more from another inpatient experience. But then 2 months is probably enough for anybody to gain what they need to gain.

 

[cookymonster]

I know some programs do half inpatient and half outpatient for your 4 months of primary care, but they do seem to be the minority. Personally I've done a ton of work at our free clinic, so I'm pretty comfortable with outpatient medicine and think I'd actually gain more from another inpatient experience. But then 2 months is probably enough for anybody to gain what they need to gain.

Do you remember any of these programs offhand?

 

[Doctor Bagel]

Do you remember any of these programs offhand?

OU-Tulsa immediately comes to mind. You can pick either IM, peds or FM for your primary care months, and it's split between outpatient and inpatient. New Mexico has one month of inpatient IM, and you get to pick what you want to do for the next 3 months. Dartmouth has 2 blocks of inpatient, one block of outpatient and one of ED.

 

[whopper]

I actually enjoy inpatient medicine quite a bit...when it's not in a sweatshop environment.

I liked IM where I did it except for a few things. 1) I spent hours a day just looking for charts. That was a pain. 2) the nursing staff tried to dump work on me. They'd beep me for non-teaching patients because they were too scared to bug an attending. However when I'd ask them over the phone if the patient was teaching or not, they'd say the patient was a teaching patient. That occurred about 20-30% of the time. That IMHO is too high a figure, and indicated they were abusing the resident. 3) I got beeped about every 5-15 minutes. It was difficult to actually get my mind into something because right when I got there--BEEP! 4) the PD and the culture of the IM program where I was at was heavy on the pimping.

Aside from that I thought IM was very interesting.

IMHO the rotation needs to be more intense that outpatient. Reason being is that when you do C&L, you will have some very intense cases. From my own anectdotal experience, psychiatry residents who only do outpatient didn't seem to have as in depth knowledge of interpreting labs dealing seeing the person as a whole. I also thought ICU was overkill, however Doc Samson who is a C&L psychiatrist stated he believes doing ICU is a good idea. Since he has more knowledge, I'd strongly factor in his advice.

"a lot of medicine programs rely on interns rotating through the wards as nothing more than slave labor, with minimal added educational value."

I agree there too. I can remember several times a resident was in a jam. The attendings in some cases didn't treat the person like a human being-e.g. the resident just deliverd a few weeks before, and was having continence problems. The attendings in IM gave her no leniency and expected her to do just as much work. (My psychiatry attendings would've excused the resident). What had to happen was other residents had to do her work for her, on top of their other responsibilities. They were willing to do it because they knew she wasn't malingering. Or attendings expecting residents to do several things in the name of professionalism that they didn't do themselves. E.g. if a resident was beeped and didn't call within 10 minutes they could get in trouble. Oh--but its okay for an attending to not return a phone call for 45 minutes if ever. I guess they didin't have to be professional.

I feel very justified in that criticism because I was an attending last year, and if I ever expected someone under me to act in a certain manner, I held myself to the same standard. If I ever didn't call back in a timely manner I tried to figure out what caused the problem (e.g beeper malfunction). Its just common decency as a human being which I figure any doctor including an attending should exhibit. When I was chief, if an attending wasn't teaching or doing their responsibilities for the residents, I wouldn't put a resident on their call if it could be avoided. (Sometimes it couldn't). Of course that drew the ire of the attendings that didn't teach. I was actually hoping they might complain because that would just bring up their lack of teaching. What are they going to do? Go to the head of the department and complain, when the chair knew I was doing it becuase they were slacking? If the attending ever complained to me, I'd just tell that person to bring it up to the program director or dept chair who has the final say on calls. I didn't get any complaints either from the head of the department who I talked with about the situation to make sure I wasn't doing anything wrong. If they want a resident, then they're supposed to teach a resident. Yes a resident is supposed to their work as well, but its not a 100/0 relationship. An attending's added teaching responsibilities vs a nonteaching attending IMHO make their jobs easy vs the amount of work a decent resident relieves them.

 

[Psychelle]

I think the ratio of inpatient to outpatient training can also be a fair criticism of medical school in general, at least from my experience during the past year. As students we spend almost our entire experience working on inpatient teams, and the reality is that many (most?) physicians primarily work in an office setting, which requires a completely different skill set. I still remember being terrified my first day of family medicine knowing that I had to get a history, do an exam, figure out the problem and come up with a management plan in mere minutes. This was at the very end of my third year, but I just wasn't used to having to think on my feet quite that quickly. Even on a busy service, there is a certain luxury to treating patients in the hospital, and a security that they're still going to be there in a few hours while you're looking stuff up.

Managing a day's worth of appointments is a completely different job, and it takes practice to find a balance between efficiency and making sure each patient gets what they need.

Now if you had asked me what I actually liked doing in the last year, I would say that there were quite a few rotations in which the worst parts were going to outpatient clinics. Generally in the hospital you knew that if you weren't on call and you got your stuff done, an afternoon was yours to study and/or leave. The same cannot be said of many an interminable, overbooked clinic of hell running three hours behind and with no hope of escape until the last angry patient had been seen. If attending wants to spend his one half-day of clinic a week musing on "the good ol days" and talking about his cars while his patients fume in the waiting room that is fine, but expecting everyone else to partake in such a supreme waste of time... Okay maybe that was just one guy's clinic, and I'm still bitter. 😛 But I definitely spent a lot of time in clinics feeling completely useless or worse, like I was creating extra work for the residents and attendings.

Anyway, it seems to me that during residency we get so much training in outpatient psych, that I don't mind primarily inpatient work during intern year. After all, even as an outpatient doctor we won't be the primary care giver managing a patient's htn, dm, etc etc so as long as I feel plenty comfortable with outpatient psychiatric care, I think I'm okay with not a lot of other outpatient experiences.

 

[whopper]

IMHO inpatient is more important in training vs outpatient. Reason being that in inpatient, things are more serious and more life threatening. If you can get inpatient down, you will be able to get outpatient too.

However a good training program needs exposure to both. To ignore outpatient could lead to a doctor who forgets to ask important factors that are not often asked in inpatient such as the person's day to day affairs, primary care etc. Just that IMHO the inpatient needs more emphasis.

Where I did my IM training we did 1 month outpatient, 3 months inpatient. I thought that was a good mix. I've seen programs where they only did outpatient, and IMHO those programs didn't have residents trained as well in the more serious aspects of IM which are important in psychiatry. E.g. I had a patient who was transferred from surgery to the psychiatry ward while he was still bleeding internally. I was able to handle it and get him transferred off the unit while informing the medical and surgical floor of his need for an IV because of my experience with dealing with inpatient medical patients. The attendings from those other departments of course tried to block the transfer (as they always do). The training from inpatient allowed me to handle them appropriately and convince the surgeon the transfer was needed (which it was.) I don't think a psychiatrist who did only outpatient during his/her IM rotations would have been as well prepared.

 

[masterofmonkeys]

I personally think an ideal balance would be 2 months inpatient, 1 month outpatient, and one month ED/urgie. Inpatient exposure is critical I think to being able to handle both inpatient psych when medical urgencies/emergencies do pop up, as well as for c/l. But there is a totally different mindset and emphasis to outpatient medicine that it behooves us as practitioners to be at least familiar with, if not competent at.

For some of our more disadvantaged patients, the only doctors they're ever likely to see are their psychiatrists. Like it or not, you may be forced into that primary care role (such as starting a homeless diabetic patient on oral hypoglycemics)

 

[strangeglove]

Outpatient medicine is one of the most boring experiences I ever had as a medical student, and I would not want to repeat it for that reason alone.
The training that you receive on a busy inpatient unit is about more than just learning the management of specific medical problems. It has to do with feeling competent making decisions that could save people's lives or kill them. That's what we're licensed to do, and you don't get that experience in outpatient medicine. Also, inpatient medicine teaches the very important lessons of how to prioritize and juggle multiple problems in your head at once, which serves you well even in outpatient psychiatry. Fine, you don't know how to manage routine diabetes and hypertension, but then you can always just read a textbook for that.

 

[Doc Samson]

As a psychiatrist, you'll never be practicing outpatient medicine. Inpatient medicine teaches you two broad lessons:

1) Enough medicine that you'll have a clue what your patients are going through when you're on CL.

2) Enough medicine that you can at least help stabilize a crashing patient on an inpatient psychiatry unit long enough for the internists to get there.

In actual practice, if your psychiatry outpatient complains of a sore throat, you're sending them to their PCP. If your psychiatry inpatient complains of a sore throat, there'll be an internist or an NP assigned to the unit to take care of it for you.

 

[billypilgrim37]

If your psychiatry inpatient complains of a sore throat, there'll be an internist or an NP assigned to the unit to take care of it for you.

I take care of sore throats all the time, thank you very much! 😉