4th resident to commit suicide at LLUMC since July... (3/4 are anesthesia residents)

[zero0]

Agreed - a lot of residency stuff these days is spent on nonsensical, non-doctor tasks. That's why I have little patience or respect for those who claim residency needs to be extended if hours are restricted.

During internship as a medicine PGY-1 I too spent countless hours faxing forms to get records, managing prior authorization nonsense, making appointments for patients, creating lists, telling ancillary staff to do their jobs, and writing handwritten notes despite my hospital having half of an EMR. The actual time spent doctoring was disheartening. It was all dispo, forms, and doing other people's jobs. And what did all of the hordes of administrators or ancillary staff do - those who were employed to assist the doctors? Lunch, "meetings", and heading home early due to family needs. None of that for us though - we were demanded to stay late, smile, work holidays, never complain, lie on hours worked, and do the work till the work was done. Can't do or won't do is never an option.

As an anesthesiology resident I had plenty of wasted time too. Induce the patient --> wait an hour in the OR till the surgeon showed up. Finish the case --> oh now you're on an 8 hour ICU hold while everybody screws around and you make sure the patient doesn't die... at 3am. On call you stay up all night to pre-op every patient for tomorrow so that the overlords (and CRNAs) have a nice easy pre-op day. The patient isn't being sent from the floor fast enough? Go pick them up yourself from the floor while the "transport team" hired to do that job is nowhere to be found. Oh and wipe down your machine, re-stock your cart, and go to the pharmacy to re-stock all the meds they never put in your med cart. They hire techs, but they don't do that (what DO then do?) And then stay for "teaching rounds" after you've been working for 28 hours straight. Now pay for your board exams and medical license that you'll never be reimbursed for and watch your student loans explode.

Then you're a senior resident with an abstract accepted to a conference and the department waffles on whether they'll give you time off to go... and they won't reimburse you due to "the budget". Oh and when they give you permission you share a hotel room with two other people... two other doctors. Three of you with 4 years of undergrad, 4 years of med school, and nearly 4 years of post-graduate training are sharing one room because you can't afford it otherwise.

All the while a 22 year old HR lackey with a degree in communications gets all expenses paid conference trips with hotel rooms at the W and comped meals at Nobu. They get paid more than you. And if they don't like the job they'll soon jump to the next one for more pay with better perks. They have had employer match for their 401k too, while your residency scoffs at this being something that could ever happen. So you've got no retirement savings at all.

As a resident you're trapped in ****hole. The only way out is to smile, nod, and beg for more absurdity. If you complain your career and financial life will be vengefully ruined. How dare you complicate the staffing or the schedule!? Oh and heaven forbid you ever consider having a child during all of this...

I could stomach all of this nonsense, barely, but it wore on me. For those with emotional or mental health issues... I'm not surprised it might push them over the edge.

Modern medical training is rotten to the core for the reasons I and others cited. It's infantilizing and traps high-achieving people in a prison with no options and with no respect while their peers can prosper in a world with options, better pay, and way more respect. Things in medicine are on track to get much much worse and will likely never be fixed (now there is astronomical med school tuition, no subsidized student loans, more administrators and ancillary staff who do nothing, more midlevels who claim to do your job better with their online "doctoral" degrees, now you'll get less pay, there are higher home prices, and there's way less respect overall for physicians).

I like (but don't love) my job as an attending. But often I hated my "job" and life as a resident. The pestilence of residency and medicine needs to be fixed.

Yup, from the start of med school 'till the end of residency they own your bitch ass. I knew that and made the call anyway but, from what I've seen, most people don't. No amount of nursing home volunteering or pre-med classes can prepare you for life on the inside. The closest thing to the lack of respect, freedom, human dignity, and fear for one's life/career you see in medicine really is prison, and at least no one expects anything from you there. The cherry on top of course is that if you even think to complain about any of this or, God forbid, try to change it, your ass will be out of there so fast your head will spin. Then what will you do with 200k in loans hanging over your head? You're trapped like a rat with no way out. It's a wonder more people don't kill themselves.

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[VA Hopeful Dr]

I did an internal medicine residency and I did a lot of faxing forms to get outside hospital medical records and answering nursing pages at 2am for a lotion order to treat a patient's dry skin. The hours of my life spent filling out discharge paperwork are hours that I will never get back.

I personally think internal medicine residency is too long as it is. I think the training could be completed in 2 years if we cut some of the fat out. I think anesthesia residency could be cut by a year as well. The idea that if we cut work hours then we would have to extend residency doesn't make much sense to me when we have midlevels doing our same jobs independently with less time training. That's a discussion for another thread, though.

Man my residency must have been better than I thought. I put in an order for records that took 2 mouse clicks and was done. A dictated discharge summary took maybe 10 minutes if they had been there since before I got on service otherwise less, we had a standard set of orders that covered irritating stuff like dry skin.

I'd rather restrict midlevels than shorten our training, but you're right that is another thread.

I could see though cutting out unrelated intern years like anesthesia or radiology but I don't know enough to have a strong opinion one way or another.

 

[Mman]

Granted I didn't do an anesthesia residency, but there was very little in my training that seemed like just using me for cheap labor. I mean, on inpatient we rarely admitted more than 5-7 patients/24 hours. At most, that's 1 full time attending. To accomplish that we had a team of 3-4 interns and 2 upper levels. Hiring another physician would have been cheaper than all of us doing the work, and fairly inefficiently I would say.

While you may have felt like hiring an attending would have been cheaper, keep in mind that for 3 interns and 2 residents your hospital was being paid about $575,000 a year by Medicare funds ($115,000 per resident per year) to offset the cost of your salary and benefits and education. I kinda doubt it would've been cheaper for the hospital to fire all 5 of you and replace you with a new attending salary while giving up that Medicare money.

 

[VA Hopeful Dr]

While you may have felt like hiring an attending would have been cheaper, keep in mind that for 3 interns and 2 residents your hospital was being paid about $575,000 a year by Medicare funds ($115,000 per resident per year) to offset the cost of your salary and benefits and education. I kinda doubt it would've been cheaper for the hospital to fire all 5 of you and replace you with a new attending salary while giving up that Medicare money.

When You Subtract salary and benefits from that based on cost when I was a resident 5 years ago, you are left with between 25 and 30000 per resident per year. Given that there was an attending on that service that had to be paid, the leftover from five residence is the salary with nothing to spare for benefits or anything else like residency Administration. So at worst it would be a wash, more likely the hospital and come out ahead given how our service load was usually a fair bit less than what all of the hospitalists were seeing on a daily basis.

 

[Mman]

When You Subtract salary and benefits from that based on cost when I was a resident 5 years ago, you are left with between 25 and 30000 per resident per year. Given that there was an attending on that service that had to be paid, the leftover from five residence is the salary with nothing to spare for benefits or anything else like residency Administration. So at worst it would be a wash, more likely the hospital and come out ahead given how our service load was usually a fair bit less than what all of the hospitalists were seeing on a daily basis.

it's still cheaper to have residents with the attached funding than to replace you with an attending that has nothing offsetting their salary and benefits.

 

[VA Hopeful Dr]

it's still cheaper to have residents with the attached funding than to replace you with an attending that has nothing offsetting their salary and benefits.

You mean like the money they're generating seeing more patients?

 

[GravelRider]

Man my residency must have been better than I thought. I put in an order for records that took 2 mouse clicks and was done. A dictated discharge summary took maybe 10 minutes if they had been there since before I got on service otherwise less, we had a standard set of orders that covered irritating stuff like dry skin.

I'd rather restrict midlevels than shorten our training, but you're right that is another thread.

I could see though cutting out unrelated intern years like anesthesia or radiology but I don't know enough to have a strong opinion one way or another.

A team of 3-4 interns and 2 upper level residents doing 5-7 admissions in a 24 hour period seems pretty atypical to me. That's less than 2 admissions per intern in a 24 hour period. Maybe I was unlucky, but my internal medicine residency was a lot higher volume than that. I finished about 6 years ago, so maybe things have changed. Also, if I remember correctly, there was a patient load cap for interns, but not for upper level residents. When my intern had gotten crushed with admissions, it was not uncommon for me to carry my own set of patients in addition to the ones I was managing with the intern.

There's a reason small community hospitals with no business maintaining residency programs are trying to start residency programs. I'll give you a hint...it's not out of some commitment to education.

 

[GravelRider]

You mean like the money they're generating seeing more patients?

Money generated seeing patients? I was a hospitalist at a large city hospital and I would say at least 80% of my patients were Medicare, Medicaid, or homeless. I was not generating much revenue for the hospital.

 

[anbuitachi]

A team of 3-4 interns and 2 upper level residents doing 5-7 admissions in a 24 hour period seems pretty atypical to me. That's less than 2 admissions per intern in a 24 hour period. Maybe I was unlucky, but my internal medicine residency was a lot higher volume than that. I finished about 6 years ago, so maybe things have changed. Also, if I remember correctly, there was a patient load cap for interns, but not for upper level residents. When my intern had gotten crushed with admissions, it was not uncommon for me to carry my own set of patients in addition to the ones I was managing with the intern.

There's a reason small community hospitals with no business maintaining residency programs are trying to start residency programs. I'll give you a hint...it's not out of some commitment to education.

that's pretty low volume if you got 5-6 people and only 5-7 admissions in 24 hrs

 

[Mman]

You mean like the money they're generating seeing more patients?

I'll go out on a limb and suggest the number of admissions to a hospital neither increases nor decreases based on having a service with residents or not. It merely shuffles around who is doing the admitting.

 

[anbuitachi]

I'll go out on a limb and suggest the number of admissions to a hospital neither increases nor decreases based on having a service with residents or not. It merely shuffles around who is doing the admitting.

I think its at least somewhat correlated if you dont replace them with attendings.. Since with more people, you see more patients in the ED, the more patients you see, the more admits you get. Unless the ED is just half empty, and adding people wont help, but otherwise if it's a normal ED that always have a line in the wait room, then i think having more people increase admits. Same with surgical admits. 100 attendings with 200 residents get more cases done in one day than 100 attendings. More cases is more surgical admits as well.

 

[Mman]

I think its at least somewhat correlated if you dont replace them with attendings.. Since with more people, you see more patients in the ED, the more patients you see, the more admits you get. Unless the ED is just half empty, and adding people wont help, but otherwise if it's a normal ED that always have a line in the wait room, then i think having more people increase admits. Same with surgical admits. 100 attendings with 200 residents get more cases done in one day than 100 attendings. More cases is more surgical admits as well.

medicine admits are based on hospital capacity and patients in ED meeting criteria for admission. Adding more docs doesn't let you admit more people since that implies they were getting sent home previously despite needing admission.

 

[anbuitachi]

medicine admits are based on hospital capacity and patients in ED meeting criteria for admission. Adding more docs doesn't let you admit more people since that implies they were getting sent home previously despite needing admission.

But can 1 attending discharge as many as 4 residents and create those beds? Care slows down when # of docs decrease. Can the 1 attending get outside records, attend social work rounds, write progress notes, discharge notes, etc as quickly as 4 residents put together? I think if you have a slow down at any part of the process, it will delay discharge, and thus delay beds for admission. Here we don't discharge 24/7, we usually discharge before certain hour. I remember days where we had sudden decompensation of patient on our service and we end up staying a long time there just for the patient. With a team, the other members can help do the rest of the work. If it's just 1 attending, she'd have to take care of that and then do the rest of the work.

 

[VA Hopeful Dr]

A team of 3-4 interns and 2 upper level residents doing 5-7 admissions in a 24 hour period seems pretty atypical to me. That's less than 2 admissions per intern in a 24 hour period. Maybe I was unlucky, but my internal medicine residency was a lot higher volume than that. I finished about 6 years ago, so maybe things have changed. Also, if I remember correctly, there was a patient load cap for interns, but not for upper level residents. When my intern had gotten crushed with admissions, it was not uncommon for me to carry my own set of patients in addition to the ones I was managing with the intern.

There's a reason small community hospitals with no business maintaining residency programs are trying to start residency programs. I'll give you a hint...it's not out of some commitment to education.

Only one intern admits per 24 hours. That way you end up with q3-4 call. Figured that was obvious. We also more or less closed the service when the interns hit their caps.

I'm not sure I buy that about hospitals opening new programs. There are several hospitals in my area that are well known for caring about making as much money as possible and nothing else. They are large enough to support multiple programs but are not doing so.

 

[VA Hopeful Dr]

Money generated seeing patients? I was a hospitalist at a large city hospital and I would say at least 80% of my patients were Medicare, Medicaid, or homeless. I was not generating much revenue for the hospital.

My wife was a hospitalist and after her second year of working her group analyzed the books and realized they were being woefully underpaid for what they were earning and so everyone in the group got an automatic 10% raise. And that was with the starting salary of 210 and it average census of 10 to 16.

 

[VA Hopeful Dr]

medicine admits are based on hospital capacity and patients in ED meeting criteria for admission. Adding more docs doesn't let you admit more people since that implies they were getting sent home previously despite needing admission.

Yes, but it's been well documented that Resident run Services have increasing length of stay compared to attending run services. So you will get more turnover more Admissions and more patients as opposed to more people boarding in the ER.

 

[VA Hopeful Dr]

But can 1 attending discharge as many as 4 residents and create those beds? Care slows down when # of docs decrease. Can the 1 attending get outside records, attend social work rounds, write progress notes, discharge notes, etc as quickly as 4 residents put together? I think if you have a slow down at any part of the process, it will delay discharge, and thus delay beds for admission. Here we don't discharge 24/7, we usually discharge before certain hour. I remember days where we had sudden decompensation of patient on our service and we end up staying a long time there just for the patient. With a team, the other members can help do the rest of the work. If it's just 1 attending, she'd have to take care of that and then do the rest of the work.

Yes, easily. In my residency as I said our service usually had around 16 patients on it. Each attending hospitalist had a service with between 25 and 30 patients on it.

 

[anbuitachi]

Yes, easily. In my residency as I said our service usually had around 16 patients on it. Each attending hospitalist had a service with between 25 and 30 patients on it.

Well I didn't mean a hospitalist can't handle it . Course they can. I mean if you gave that same hospitalist 4 residents would there be faster discharged and more beds.

 

[dchz]

When I was in training, the thing that weighed on me most, and at times pushed me in the general direction of burnout, wasn't the long hours, the sleep deprivation, or taking another human's life into my hands several times per day.

It was being a grown up adult, a married man, a father, a person who made the cut to get into medical school and graduated and passed the USMLE, a person who held an unrestricted license to practice medicine ... and yet I lived and worked in this surreal kindergarten-like world where I and a bunch of other people like me were constantly seeking approval from attendings like they were distantly neglectful parents.

I don't remember having that kind of relationship with my professors in college or medical school. There wasn't a culture that revolved around "staying off the radar" or pleasing anyone. In my interactions with them, I was a respected adult learner, and they were there to guide me. Somehow, when I became an intern, I became a child again. And to make it worse, to an extent I embraced that role because I understood it to be the only way I'd be able graduate and move on to a less caustic place in life.

I actually felt worse about it because I voluntarily assumed that role.

I'm just an armchair psychiatrist, but I can't help but think of of Maslow's hierarchy of needs. You've got a bunch of mature adult high achievers, fresh out of medical school, in that top self-actualization tier of the pyramid, and then they enter the world of GME and get roughly kicked down to a level where all of a sudden the overriding concerns are for "security, order, law, stability, freedom from fear" ... one bare notch above basic biological needs for food and shelter. Safety needs.

That stuff at the top of the pyramid is important, and while residency could and should be structured to lift people up, too often it feels like we've created some kind of gradeschool-esque popularity contest where the residents need to show a smile, never show a sign of fatigue, always verbalize enthusiasm about that high-value afternoon wound washout add-on case aka opportunity to excel even when we know they're just as disappointed in getting an extra couple hours of low-yield labor as we are.

Over and over again I've seen very junior trainees who are just as incompetent as their peers, but their demeanor, speech patterns, personality, sense of humor get them "on the radar".

A majority of staff eval narratives include comments on attitude. Even when complimentary, when residents see such comments, it just reinforces the notion that they're being judged on nonclinical personality trait intangibles.

There's something fundamentally pathological and humiliating about our system. It's no wonder that physician burnout, depression, and suicide are such problems. I think we fixate on work hours being the main culprit waaaaaay too much. We're the better part of two decades into this work hour limit experiment and residents are still burning out and killing themselves. It's not because they're tired.

I think it's because the system makes them feel small.

If 1/10th of the attendings in academia could see it this way, the world would be 100x better.

 

[GravelRider]

Only one intern admits per 24 hours. That way you end up with q3-4 call. Figured that was obvious. We also more or less closed the service when the interns hit their caps.

I'm not sure I buy that about hospitals opening new programs. There are several hospitals in my area that are well known for caring about making as much money as possible and nothing else. They are large enough to support multiple programs but are not doing so.

Still seems low volume, but then again maybe I was just unlucky. I also don't know many hospitalists seeing 30 patients a day. That seems way above average. My guess (last time I checked) is that the average is probably somewhere around 15-20.

A lot of it probably has to do with payer mix. The hospital with a lot of self-pay and private insurance patients may not need residents, but the hospital that I describe with a lot of Medicare, Medicaid, and indigent will have residency programs to offset cost. It's heart warming that you think hospitals have residency programs out of a dedication to education, but I just don't think that is the case.

 

[Mman]

Yes, but it's been well documented that Resident run Services have increasing length of stay compared to attending run services. So you will get more turnover more Admissions and more patients as opposed to more people boarding in the ER.

I kinda doubt the ED has people boarding for days at a time awaiting admission. I mean that's the sort of thing that gets on the front page of the news and gets hospital CEOs fired.

 

[MaximusD]

When I was in training, the thing that weighed on me most, and at times pushed me in the general direction of burnout, wasn't the long hours, the sleep deprivation, or taking another human's life into my hands several times per day.

It was being a grown up adult, a married man, a father, a person who made the cut to get into medical school and graduated and passed the USMLE, a person who held an unrestricted license to practice medicine ... and yet I lived and worked in this surreal kindergarten-like world where I and a bunch of other people like me were constantly seeking approval from attendings like they were distantly neglectful parents.

I don't remember having that kind of relationship with my professors in college or medical school. There wasn't a culture that revolved around "staying off the radar" or pleasing anyone. In my interactions with them, I was a respected adult learner, and they were there to guide me. Somehow, when I became an intern, I became a child again. And to make it worse, to an extent I embraced that role because I understood it to be the only way I'd be able graduate and move on to a less caustic place in life.

I actually felt worse about it because I voluntarily assumed that role.

I'm just an armchair psychiatrist, but I can't help but think of of Maslow's hierarchy of needs. You've got a bunch of mature adult high achievers, fresh out of medical school, in that top self-actualization tier of the pyramid, and then they enter the world of GME and get roughly kicked down to a level where all of a sudden the overriding concerns are for "security, order, law, stability, freedom from fear" ... one bare notch above basic biological needs for food and shelter. Safety needs.

That stuff at the top of the pyramid is important, and while residency could and should be structured to lift people up, too often it feels like we've created some kind of gradeschool-esque popularity contest where the residents need to show a smile, never show a sign of fatigue, always verbalize enthusiasm about that high-value afternoon wound washout add-on case aka opportunity to excel even when we know they're just as disappointed in getting an extra couple hours of low-yield labor as we are.

Over and over again I've seen very junior trainees who are just as incompetent as their peers, but their demeanor, speech patterns, personality, sense of humor get them "on the radar".

A majority of staff eval narratives include comments on attitude. Even when complimentary, when residents see such comments, it just reinforces the notion that they're being judged on nonclinical personality trait intangibles.

There's something fundamentally pathological and humiliating about our system. It's no wonder that physician burnout, depression, and suicide are such problems. I think we fixate on work hours being the main culprit waaaaaay too much. We're the better part of two decades into this work hour limit experiment and residents are still burning out and killing themselves. It's not because they're tired.

I think it's because the system makes them feel small.

I've gotta say that this is one of the most thoughtful and revealing posts I have ever read on SDN. Thank you, sincerely. I couldn't agree more.

 

[deleted162650]

When I was in training, the thing that weighed on me most, and at times pushed me in the general direction of burnout, wasn't the long hours, the sleep deprivation, or taking another human's life into my hands several times per day.

It was being a grown up adult, a married man, a father, a person who made the cut to get into medical school and graduated and passed the USMLE, a person who held an unrestricted license to practice medicine ... and yet I lived and worked in this surreal kindergarten-like world where I and a bunch of other people like me were constantly seeking approval from attendings like they were distantly neglectful parents.

I don't remember having that kind of relationship with my professors in college or medical school. There wasn't a culture that revolved around "staying off the radar" or pleasing anyone. In my interactions with them, I was a respected adult learner, and they were there to guide me. Somehow, when I became an intern, I became a child again. And to make it worse, to an extent I embraced that role because I understood it to be the only way I'd be able graduate and move on to a less caustic place in life.

I actually felt worse about it because I voluntarily assumed that role.

I'm just an armchair psychiatrist, but I can't help but think of of Maslow's hierarchy of needs. You've got a bunch of mature adult high achievers, fresh out of medical school, in that top self-actualization tier of the pyramid, and then they enter the world of GME and get roughly kicked down to a level where all of a sudden the overriding concerns are for "security, order, law, stability, freedom from fear" ... one bare notch above basic biological needs for food and shelter. Safety needs.

That stuff at the top of the pyramid is important, and while residency could and should be structured to lift people up, too often it feels like we've created some kind of gradeschool-esque popularity contest where the residents need to show a smile, never show a sign of fatigue, always verbalize enthusiasm about that high-value afternoon wound washout add-on case aka opportunity to excel even when we know they're just as disappointed in getting an extra couple hours of low-yield labor as we are.

Over and over again I've seen very junior trainees who are just as incompetent as their peers, but their demeanor, speech patterns, personality, sense of humor get them "on the radar".

A majority of staff eval narratives include comments on attitude. Even when complimentary, when residents see such comments, it just reinforces the notion that they're being judged on nonclinical personality trait intangibles.

There's something fundamentally pathological and humiliating about our system. It's no wonder that physician burnout, depression, and suicide are such problems. I think we fixate on work hours being the main culprit waaaaaay too much. We're the better part of two decades into this work hour limit experiment and residents are still burning out and killing themselves. It's not because they're tired.

I think it's because the system makes them feel small.

Wow @pgg, that post was very “snowflakey” for you.

 

[VA Hopeful Dr]

I kinda doubt the ED has people boarding for days at a time awaiting admission. I mean that's the sort of thing that gets on the front page of the news and gets hospital CEOs fired.

Not days plural, but throughout med school and residency there would be people boarding for 12+ hours, usually get beds every afternoon after AM discharges. Lower length of stay means more discharges which means those folks get beds faster and so on.

 

[VA Hopeful Dr]

Still seems low volume, but then again maybe I was just unlucky. I also don't know many hospitalists seeing 30 patients a day. That seems way above average. My guess (last time I checked) is that the average is probably somewhere around 15-20.

A lot of it probably has to do with payer mix. The hospital with a lot of self-pay and private insurance patients may not need residents, but the hospital that I describe with a lot of Medicare, Medicaid, and indigent will have residency programs to offset cost. It's heart warming that you think hospitals have residency programs out of a dedication to education, but I just don't think that is the case.

Not saying it's good patient care as it's quite obviously not, but I've seen it at 2 different hospitals half a state apart.

I always thought it was done as a prestige thing. Now they can call themselves an academic center or whatever. I mean, I didn't think CMS had expanded residency funding. If that's true (and it might not be, I'm not sure), how are residents in these new places making their hospitals money if there is no CMS backing?

 

[nimbus]

100 attendings with 200 residents get more cases done in one day than 100 attendings. More cases is more surgical admits as well.

I doubt this very much. Attending only can do a gallbladder in 20min vs 120min+ that was routine at my old training program.

 

[abolt18]

I kinda doubt the ED has people boarding for days at a time awaiting admission. I mean that's the sort of thing that gets on the front page of the news and gets hospital CEOs fired.

My hospital constantly has many boarders in the ED. I have seen many patients spend several days boarding in the ED. We get emails a few times a month informing us the hospital is full and "please discharge anyone who is medically appropriate for discharge."

Our ORs are often on PACU hold because there's not enough rooms and we can't get people out of PACU and up to the floor. Our hospital is perpetually in a state of being full or overfull.

 

[Mman]

Not days plural, but throughout med school and residency there would be people boarding for 12+ hours, usually get beds every afternoon after AM discharges. Lower length of stay means more discharges which means those folks get beds faster and so on.

still doesn't increase number of admissions, only decreases ED time til admission

 

[Mman]

My hospital constantly has many boarders in the ED. I have seen many patients spend several days boarding in the ED. We get emails a few times a month informing us the hospital is full and "please discharge anyone who is medically appropriate for discharge."

Our ORs are often on PACU hold because there's not enough rooms and we can't get people out of PACU and up to the floor. Our hospital is perpetually in a state of being full or overfull.

I'm amazed your hospital hasn't been shut down

 

[abolt18]

I'm amazed your hospital hasn't been shut down

I don't understand why this would lead to being shut down. There are 3 other hospitals within about 1-2 miles of us, but ours handles the highest acuity issues.

It's a 975 bed hospital. More than half of the state depends on us to provide the care they can't get anywhere else even remotely nearby. Our hospital has a policy to accept any transfers from OSHs. People are regularly transferred from small hospitals 4 hrs away.

What do you do when the volume is higher than you can handle? Close the hospital? Seems counterintuitive. Much of the care will trickle down to the nearby hospitals, but once patients get really sick, they'll just send them to us anyway.

 

[anbuitachi]

I doubt this very much. Attending only can do a gallbladder in 20min vs 120min+ that was routine at my old training program.

I dont think the 100 min is the anesthesia difference. I think thats the surgeon difference

 

[VA Hopeful Dr]

still doesn't increase number of admissions, only decreases ED time til admission

It shifts everything forward which has the same effect.

Plus you get a decrease in your LWBS numbers which likely increases admissions.

 

[Mman]

I don't understand why this would lead to being shut down. There are 3 other hospitals within about 1-2 miles of us, but ours handles the highest acuity issues.

I'd have to see which state exactly but I'm pretty sure it is at least violating CMS guidelines to keep someone in an ED for days.

 

[abolt18]

I'd have to see which state exactly but I'm pretty sure it is at least violating CMS guidelines to keep someone in an ED for days.

They've designated a small area as "ED Observation" with some 30-40 beds where they get moved to of they can't get up to the floor. But it's still officially in the ED. And not everyone in that area is being admitted. There are hallway beds in addition to rooms.

I can't pretend I know the laws and regulations. I can only tell you what I've seen. I've had several patients of mind spending multiple days down there. They must get away with it on some technicality.

 

[Guillemot]

In the past I've had to put up with malignant/narcissistic attendings whose abilities often ranged anywhere from mediocre, to marginal competence, to dangerous. (Interesting how it works out that the bad ones also tend to be the ones with cluster B personality traits/disorders.) Can understandably be a disheartening situation, and in residency its extremely difficult to walk away and find a better deal. They own you.

 

[anbuitachi]

I don't understand why this would lead to being shut down. There are 3 other hospitals within about 1-2 miles of us, but ours handles the highest acuity issues.

It's a 975 bed hospital. More than half of the state depends on us to provide the care they can't get anywhere else even remotely nearby. Our hospital has a policy to accept any transfers from OSHs. People are regularly transferred from small hospitals 4 hrs away.

What do you do when the volume is higher than you can handle? Close the hospital? Seems counterintuitive. Much of the care will trickle down to the nearby hospitals, but once patients get really sick, they'll just send them to us anyway.

sounds like a typical large city hospital

 

[acidbase1]

In a sick demented way reading threads like this makes me feel better, that I’m not alone in how I feel about this process. It’s been 10 years of pure hell

 

[MaximusD]

In a sick demented way reading threads like this makes me feel better, that I’m not alone in how I feel about this process. It’s been 10 years of pure hell

Not pure hell, but unreasonably unpleasant is accurate.

 

[chocomorsel]

This thread has gone way off topic.

 

[pgg]

This thread has gone way off topic.

Discussions do that ...

 

[VA Hopeful Dr]

This thread has gone way off topic.

But in a worthwhile way, especially pgg's comment. Might be the most insightful post I've ever seen here.

 

[chocomorsel]

But in a worthwhile way, especially pgg's comment. Might be the most insightful post I've ever seen here.

That part fit perfectly in to this discussion. Then it lead to the whole running of hospitals, how many doctors are needed, how much money the government pays, blah blah blah. Those need a different thread IMO.

 

[deleted547339]

Only one intern admits per 24 hours. That way you end up with q3-4 call. Figured that was obvious. We also more or less closed the service when the interns hit their caps.

I'm not sure I buy that about hospitals opening new programs. There are several hospitals in my area that are well known for caring about making as much money as possible and nothing else. They are large enough to support multiple programs but are not doing so.

HCA started opening residencies....

 

[deleted547339]

I'm amazed your hospital hasn't been shut down

I’ve did residency and am now doing fellowship at two strong programs and both had significant problems with this. It’s a nationwide problem. Shocked you don’t have that problem where you practice.

 

[anbuitachi]

I’ve did residency and am now doing fellowship at two strong programs and both had significant problems with this. It’s a nationwide problem. Shocked you don’t have that problem where you practice.

I imagine many of the successful teaching hospitals must be like that. margins are pretty thin these days and hospitals do whatever they can to make money. So their goal is pretty much always full capacity

 

[VA Hopeful Dr]

HCA started opening residencies....

Didn't the ER forum suggest this was done to get them naive first year attendings they could hire for peanuts?

 

[nimbus]

When I was in training, the thing that weighed on me most, and at times pushed me in the general direction of burnout, wasn't the long hours, the sleep deprivation, or taking another human's life into my hands several times per day.

It was being a grown up adult, a married man, a father, a person who made the cut to get into medical school and graduated and passed the USMLE, a person who held an unrestricted license to practice medicine ... and yet I lived and worked in this surreal kindergarten-like world where I and a bunch of other people like me were constantly seeking approval from attendings like they were distantly neglectful parents.

I don't remember having that kind of relationship with my professors in college or medical school. There wasn't a culture that revolved around "staying off the radar" or pleasing anyone. In my interactions with them, I was a respected adult learner, and they were there to guide me. Somehow, when I became an intern, I became a child again. And to make it worse, to an extent I embraced that role because I understood it to be the only way I'd be able graduate and move on to a less caustic place in life.

I actually felt worse about it because I voluntarily assumed that role.

I'm just an armchair psychiatrist, but I can't help but think of of Maslow's hierarchy of needs. You've got a bunch of mature adult high achievers, fresh out of medical school, in that top self-actualization tier of the pyramid, and then they enter the world of GME and get roughly kicked down to a level where all of a sudden the overriding concerns are for "security, order, law, stability, freedom from fear" ... one bare notch above basic biological needs for food and shelter. Safety needs.

That stuff at the top of the pyramid is important, and while residency could and should be structured to lift people up, too often it feels like we've created some kind of gradeschool-esque popularity contest where the residents need to show a smile, never show a sign of fatigue, always verbalize enthusiasm about that high-value afternoon wound washout add-on case aka opportunity to excel even when we know they're just as disappointed in getting an extra couple hours of low-yield labor as we are.

Over and over again I've seen very junior trainees who are just as incompetent as their peers, but their demeanor, speech patterns, personality, sense of humor get them "on the radar".

A majority of staff eval narratives include comments on attitude. Even when complimentary, when residents see such comments, it just reinforces the notion that they're being judged on nonclinical personality trait intangibles.

There's something fundamentally pathological and humiliating about our system. It's no wonder that physician burnout, depression, and suicide are such problems. I think we fixate on work hours being the main culprit waaaaaay too much. We're the better part of two decades into this work hour limit experiment and residents are still burning out and killing themselves. It's not because they're tired.

I think it's because the system makes them feel small.

I was in a different place when I started training. 25 years old, unmarried and supported by my parents for my entire life. Internship was actually the first real job I ever had. So the role was not a difficult adjustment for me, really just a continuation of 3rd and 4th year of medical school. And I was definitely not a fully actualized adult at that time.

In terms of resident evaluation, it’s no different than how we evaluate new hires rotating through our site now. Once a basic level of competence is established, attitude is everything. Anesthesia is a team sport.

And I’d say most people in medical education are incredibly supportive of medical students and trainees. I still remember surgeons, internists, ER doctors, psychiatrists, anesthesiologists who were incredibly encouraging and supportive during medical school. They taught me a lot and I’m grateful to them to this day. The malignant a**hole was definitely an exception rather than the rule. In my anesthesia residency there was not a single malignant attending in the entire department. Quirky or odd? Yes, but never malignant.

 

[nimbus]

I imagine many of the successful teaching hospitals must be like that. margins are pretty thin these days and hospitals do whatever they can to make money. So their goal is pretty much always full capacity

Yes the goal for hospitals has always been no empty beds and busy, full operating rooms. Every hospital likes that. It is a business.

 

[Mman]

I’ve did residency and am now doing fellowship at two strong programs and both had significant problems with this. It’s a nationwide problem. Shocked you don’t have that problem where you practice.

I didn't say we didn't have prolonged ER wait times for admissions, but it never stretches more than 24 hours. I'm fairly certain that would violate state CON statutes about what constitutes an inpatient bed.

 

[anbuitachi]

I didn't say we didn't have prolonged ER wait times for admissions, but it never stretches more than 24 hours. I'm fairly certain that would violate state CON statutes about what constitutes an inpatient bed.

I dont think there are laws stating where inpatients must stay.. I think they just need to be seen within certain amount of time? I mean when the ED is packed, they send up inpatients to their floor, but not to a room, but to the hallway on a stretcher