All about 2010 Interns!

[seahawk188]

In about a month, I will be an intern. I have read a lot of useful posts and will continue to read those stories and tips- I hope they will help me well prepared. I already foresee my ups and downs of my three-year residency. Oh, boy! I am sure it will be a roller coaster ride! I, for one, would like to share my intern year stories here with 2010 interns and past interns. So join me if you want!

My residency is in FM. My second block will be an off-service surgery rotation at a VA hospital. What can I expect from this rotation?

Thanks!

The feeling of going forward is always good!

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[seahawk188]

My question is: will I have scrub-in opportunities as an off-service intern, esp as a FM intern? I hope I will not just spend time writing notes, F/U, and more notes.

Another question I want to ask: what is exactly the difference between night flow and q3/q4 call?

Seniors, throw some bones, will you? Ok, not funny, just joking...

 

[Law2Doc]

...
Another question I want to ask: what is exactly the difference between night flow and q3/q4 call?

Seniors, throw some bones, will you? Ok, not funny, just joking...

First it's night FLOAT, not flow. Night float means you work nights for some period of time, eg you are on for nights from 6pm to 7am 6 days/week for a month. The nice thing about that is that in the months you aren't working nights, you have much much fewer overnight calls. q3 means you have overnight call every third day. Meaning you have a precall day, a call day and a postcall day, and then repeat. Meaning in an 80 hour work week, you may have a 10 hour precall day, a 30 hour overnight shift, and then go home and sleep by midday the next day, and then repeat, with the 7th day off each week. Only the more intense settings tend to use this because you hit the 80 hour mark pretty quickly if you do multiple 30 hour shifts per week. Some of the smaller places may go to this schedule around the winter holidays when staffing becomes an issue. q4 pushes it out another day, so that you have a precall day, a call day, a postcall day and an extra "normal day". At some places this "normal day" is a short-call day where you can admit patients up to a certain time. And so there's no confusion, when I say call I mean that you stay at the hospital overnight.

 

[gutonc]

My question is: will I have scrub-in opportunities as an off-service intern, esp as a FM intern? I hope I will not just spend time writing notes, F/U, and more notes.

It completely depends on the setting. Where I did my surgery rotation as a med student, they had a ton of prelims and a huge private surgical group at the hospital so there were always enough people to cover the floor/unit and more than enough cases going on to allow some of the interns in the OR every day.

In the hospital where I am now, prelims almost never scrub, especially at the beginning of the year. They cover the floors and see consults. Off-service interns (FM and EM) only cover the Trauma service so mostly just do notes, notes and more notes.

 

[seahawk188]

LawtoDoc, you gave me a razor sharp answer-no more confusion between night float and qwhat calls! or night float and night flow It's funny-what a green horn I am! Using night float is way better, because as interns we need to keep our head always above the water!

So according to you , night float is more managable than qwhat. Are more programs using night float nowadays or just depends?


________________________

My grandpa is a hillbilly, my dad is a bastard with a bastard filling, and I, for one, will be a doc. I can't believe it!

 

[seahawk188]

......In the hospital where I am now, prelims almost never scrub, especially at the beginning of the year. They cover the floors and see consults. Off-service interns (FM and EM) only cover the Trauma service so mostly just do notes, notes and more notes.

- Oh, that sucks!!! I hope I will not be reduced to a secretary of some kind. I need action, a month of note juggling will drive me crazy! Anyway, gutonc, thanks for the info!

Are there any more in-coming interns at SDN? I hope I will not the only one here asking for more bones, even just left-over bones.

 

[seahawk188]

...because you hit the 80 hour mark pretty quickly if you do multiple 30 hour shifts per week. ...

what do you mean by "multiple 30 hour shifts per week"? you mean more than one call per week? sorry, still

Is q4 more common than q3 these days?

 

[ShyRem]

If your call is structured where on your call day/night you come to work at (for example) 0600, stay in the hospital all day working as usual, stay in the hospital all night "on call" and then the next day work until 1200 or so, you're "on duty" for 30 hours.

If your call is Q3, let's say your schedule is:
call Sunday - 0600 Sunday -1200 Monday.
Monday short day off at 1200.
Tuesday normal work day.
Wednesday is a call day - work 0600 Wednesday -1200 Thursday.
Thursday short day
Friday normal work day.
Saturday is a call day.

thus you are working three 30 hour shifts in one week.

Unless your call is Q7, you'll have weeks you do more than one 30 hour shift, thus "multiple 30 hour shifts per week." The hours add up quickly. In the above scenario the workweek has about 120 hours in it. Now before you start screaming "BUT I'M LIMITED TO 80 HOURS A WEEK", bear in mind that those work week limitations are often defined as an AVERAGE for the month. So you can work a 120 work week, an 80 hour week and then two lighter 60 hour weeks and still meet work hour restrictions.

As for what is more common, I don't know. I've seen places that are Q3 all three years of IM (and some where you have to make up your call if you go on vacation, do an away rotation, etc. - I met one poor 3rd year resident who was doing Q2 call in preparation of vacation), I've seen places that have a night float system in place with no call. Some places are Q4 or Q5 call. It depends.

 

[seahawk188]

Now I finally got it! Thanks a lot! 120hrs/w, man, I donno, maybe I can handle it if I think more of the 60hrs/w! I hope my program will have a night float system in place.

________________________

My grandpa is a hillbilly, my dad is a bastard with a bastard filling, and I, for one, will be a doc. I can't believe it!

 

[ShyRem]

That is something you probably wanted to look at before you ranked your program. I know it was a big factor in my rankings (e.g. the program with Q3 call you had to make up didn't make my rank list).

Edit: I hope I wasn't insensitive. It just occurred to me that there are folks who scrambled and didn't have much choice. My sincere apologies. I hope your system considers a life outside of residency important.

 

[Law2Doc]

That is something you probably wanted to look at before you ranked your program. I know it was a big factor in my rankings (e.g. the program with Q3 call you had to make up didn't make my rank list).

Edit: I hope I wasn't insensitive. It just occurred to me that there are folks who scrambled and didn't have much choice. My sincere apologies. I hope your system considers a life outside of residency important.

I think you adjust to whatever the system is. The folks with q3 or q4 call love the multiple days a week that they get out at noon, so they can actually get errands done if they managed to get a few hours of sleep in the call room during the night, the folks with night float love that they have less call the rest of the year (but may complain bitterly during the month they are on), etc. I agree that if you are in the drivers seat deciding on what makes the most sense for you one or the other plan may sound appealing. I happen to think night float, preferably getting it over with early in the year, makes the most sense for residents -- it's nice to come home for dinner most of the year once you survive your month of pain. But I certainly know proponents of q4 who seem to be loving life on the non-call days. Either way, you adapt and know that if the program is following the rules, you won't be spending over 320 duty hours/month (80 hour avg over 4 weeks). So however you slice it, you won't be spending more time in the hospital than that. It's just how you parse up that time.

I also would like to point out that much of this seems undoable while you are at the med student level, but by the end of your intern year, of all your complaints about how things are run/misrun, not being able to handle the hours won't be one of them.

 

[seahawk188]

LawtoDoc, how many blocks of night float can you get in a year? Will you get less when you became R2/R3?

 

[seahawk188]

"Interns on Inpatient Medicine stay overnight every eighth evening." Does that mean q8?

 

[Winged Scapula]

"Interns on Inpatient Medicine stay overnight every eighth evening." Does that mean q8?

Yes.

 

[Law2Doc]

LawtoDoc, how many blocks of night float can you get in a year? Will you get less when you became R2/R3?

I've heard of folks doing one or two months of night float, sometimes in one month straight shots, in other cases in 2 week shots. Overnight schedules don't always get better for R2-3s because somebody has to be available to help out the nightfloat intern when they get in over their head, which in the first few months of the year is frequent.

 

[seahawk188]

Yes.

Is q8 common for interns these days? How does it tell about the program?

____________

"When in doubt, just call." A lesson I have learned from SDN.

 

[Winged Scapula]

Is q8 common for interns these days?

Depends on the program. IMHO its a pretty cush call schedule but note that its q8 for "Inpatient Medicine" which can mean that when on MICU, and other rotations the call schedule may be more or less than q8. I don't know what is a common call schedule for IM interns but from others who do know and have posted here on SDN, I'd say most places have you on call more.

How does it tell about the program?

____________

"When in doubt, just call." A lesson I have learned from SDN.

Not much except maybe they have a LOT of interns (as many IM programs do).

 

[seahawk188]

Can you get internitis (burnt out) before senioritis?

What's the best strategies to avoid those itises? I want to really enjoy residency not suffer from it. Is it even possible?

 

[seahawk188]

I've heard of folks doing one or two months of night float, sometimes in one month straight shots, in other cases in 2 week shots. ..

Would you say night float is more common in larger programs?

 

[Law2Doc]

Would you say night float is more common in larger programs?

No. Night float is probably most common anyplace where they are pushing the limit on the 80 hour work week, because you can milk more days out of people if you don't have them staying overnight and leaving early a couple of times a week. It's really rapidly becoming the solution to the duty hour limit at most places -- expect this to be even more widespread every year.

 

[leopanther]

"Interns on Inpatient Medicine stay overnight every eighth evening." Does that mean q8?

It means that overnight call is Q8 but there still may be call outside of this where you admit patients until sometime in the evening.

 

[MattD]

No. Night float is probably most common anyplace where they are pushing the limit on the 80 hour work week, because you can milk more days out of people if you don't have them staying overnight and leaving early a couple of times a week. It's really rapidly becoming the solution to the duty hour limit at most places -- expect this to be even more widespread every year.

Even so, it's going to be more common in larger programs simply due to logistics. Perhaps in IM programs, where a small program might still consist of a dozen residents per class, it's doable, but I ran into a number of GS programs with a class size of 4-5 where they said they wanted to implement a night float but couldn't figure out how to do it without leaving services uncovered.

 

[Law2Doc]

Even so, it's going to be more common in larger programs simply due to logistics. Perhaps in IM programs, where a small program might still consist of a dozen residents per class, it's doable, but I ran into a number of GS programs with a class size of 4-5 where they said they wanted to implement a night float but couldn't figure out how to do it without leaving services uncovered.

I don't know about that -- in the area where I work, all the smaller community programs have some component of night float while the larger programs are the ones resistant to giving up their q4 schedule. The logistics work just as well with a smaller program -- if you have a dozen residents (not a big program for IM or GS) each does a month of night float; if you have 6 (ie a tiny program for IM or GS) then each will do two months. I guess it's a bit oppressive for a program of 4 people to be asked to each do 3 months of night float, but if you have prelims, it's rare to have such a small program in IM or GS.

 

[seahawk188]

Thanks for a nice session of Q&As! How about these two Qs I posted earlier:

Can you get internitis (burnt out) before senioritis?

What's the best strategies to avoid those itises? I want to really enjoy residency not suffer from it. Is it even possible?

With more q7-8 or night floats in place, is residency more enjoyable, say, than 5 years ago?

I read from some where compression socks help (your legs) during long hours, has someone here tried it? Which brand is the best? I checked on amazon, they have a brands like Jobst, or prestige. Are those OK?

 

[seahawk188]

No. Night float is probably most common anyplace where they are pushing the limit on the 80 hour work week, because you can milk more days out of people if you don't have them staying overnight and leaving early a couple of times a week. It's really rapidly becoming the solution to the duty hour limit at most places -- expect this to be even more widespread every year.

Are most hospitals or programs inclined to MILK residents these days

I know learning by doing is a great educational method, but what is the outcome by abusing it? What will happen to those didactic sessions or workshops if H/P only want to milk their residents?

 

[MattD]

I don't know about that -- in the area where I work, all the smaller community programs have some component of night float while the larger programs are the ones resistant to giving up their q4 schedule. The logistics work just as well with a smaller program -- if you have a dozen residents (not a big program for IM or GS) each does a month of night float; if you have 6 (ie a tiny program for IM or GS) then each will do two months. I guess it's a bit oppressive for a program of 4 people to be asked to each do 3 months of night float, but if you have prelims, it's rare to have such a small program in IM or GS.

Huh? 12 is a HUGE class size for a GS program. OHSU and Mayo are the only two programs off the top of my head with more than 10 in a class (although FREIDA doesn't have that info on every program.) You're right, if there are a bunch of prelims and you're ok with using the least experienced members of the team (interns) for your night float (at my school midlevels took float, but granted that's n=1), then it might work. And you're right, I can't imagine a program with 4 residents dedicating 3 months of their 60 total to a service that is neither particularly operative nor dedicated to critical care. I'm not saying it can't be done though.

 

[Law2Doc]

Huh? 12 is a HUGE class size for a GS program. OHSU and Mayo are the only two programs off the top of my head with more than 10 in a class (although FREIDA doesn't have that info on every program.) You're right, if there are a bunch of prelims and you're ok with using the least experienced members of the team (interns) for your night float (at my school midlevels took float, but granted that's n=1), then it might work. And you're right, I can't imagine a program with 4 residents dedicating 3 months of their 60 total to a service that is neither particularly operative nor dedicated to critical care. I'm not saying it can't be done though.

I think you are ignoring prelims when looking at numbers of residents in programs. Eg if you look at the ACGME lists, OHSU has a dozen categoricals, but also has 13 prelims. And your region of the country is probably not reflective of what is big/small as compared to some of the coastal cities. In a lot of the cities I'm familiar with, the smaller programs have 2-3 categoricals and maybe 8 -9 prelims as PGY-1s. The bigger programs have 2-3 times that. And around here the interns are absolutely the ones who do the night float.

 

[MattD]

I think you are ignoring prelims when looking at numbers of residents in programs. Eg if you look at the ACGME lists, OHSU has a dozen categoricals, but also has 13 prelims. And your region of the country is probably not reflective of what is big/small as compared to some of the coastal cities. In a lot of the cities I'm familiar with, the smaller programs have 2-3 categoricals and maybe 8 -9 prelims as PGY-1s. The bigger programs have 2-3 times that. And around here the interns are absolutely the ones who do the night float.

You're right, I'm definitely ignoring the prelims. In a program with 7 categoricals and 17 prelims it is inaccurate to suggest the surgery program has 24 in the class. It has 7, with an additional 17 passing through. As I acknowledged though, if you have a big prelim class and use interns for nightfloat it would work. Midlevels were the floats at my med school, but I don't doubt other places could do things differently. That being said, OHSU doesn't have a class size of 25. They graduate 12 chiefs, that's the program size.

 

[Winged Scapula]

The "average/mode" size of categorical general surgery programs is 6 residents per year.

 

[smq123]

My question is: will I have scrub-in opportunities as an off-service intern, esp as a FM intern? I hope I will not just spend time writing notes, F/U, and more notes.

How much you get to scrub in as an FM intern depends on the program, as others have said.

To be honest, I found that scrubbing in, particularly as the FM intern, was low yield. I enjoyed it, and liked hanging out with the gen surg attendings in the OR, but that's not where I learned the most. Doing consults, running consults by the attendings, and taking the attending on rounds, was actually significantly more useful - if nothing else, you will learn how to more efficiently consult surgery when you are on the inpatient medicine service. Plus, you will learn which surgeons in which groups take what kind of patients, which will help you when you see patients in the outpatient office.

- Oh, that sucks!!! I hope I will not be reduced to a secretary of some kind. I need action, a month of note juggling will drive me crazy!

If you think that carrying the service pager, and running the floor while others are in the OR, does not involve "action," then you haven't done it before. When you get paged by 3 people at the same time, you'll wish that all you were doing was standing quietly in the OR holding a retractor.

Plus, even if they let you scrub in, you probably won't be first assist, and won't be seeing any "action." You'll be holding the retractor or the camera and standing pretty still.

 

[seahawk188]

... Doing consults, running consults by the attendings, and taking the attending on rounds, was actually significantly more useful - if nothing else, you will learn how to more efficiently consult surgery when you are on the inpatient medicine service. ..

I guess I don't want to be a retractor handler, better to be on the floors then.

When you refer to attendings, are those FM attendings or Surg attendings?

 

[seahawk188]

You're right, I'm definitely ignoring the prelims. In a program with 7 categoricals and 17 prelims it is inaccurate to suggest the surgery program has 24 in the class....

You guys talk about a lot about prelims here. Are those ppl working with you on your team? Will they be on your schedule?

How many co-interns do you have on a team in a typical FM program?

 

[smq123]

I guess I don't want to be a retractor handler, better to be on the floors then.

When you refer to attendings, are those FM attendings or Surg attendings?

Surgery attendings. Very few places allow FM attendings to have operating privileges.

 

[seahawk188]

Will you have a FM senior with you during the surgery service, or just you and your co-interns?

 

[smq123]

Will you have a FM senior with you during the surgery service, or just you and your co-interns?

You'll probably have a surgery resident as your senior. It depends on your program, but that's what I would guess.

 

[seahawk188]

Here is your reward - a hillbilly joke I like to share:

Three Hillbillies are sitting on a porch shootin' the breeze.
1st Hillbilly says: 'My wife sure is stupid!...She bought an air conditioner. '
2nd Hillbilly says: 'Why is that stupid?'
1st Hillbilly says: 'We ain't got no 'lectricity!'
2nd Hillbilly says: 'That's nothin'! My wife is so stupid, she bought one of them new Fangled warshin ' machines!'
1st Hillbilly says: 'Why is that so stupid?'
2nd Hillbilly says: ''Cause we ain't got no plummin'!'
3rd Hillbilly says: 'That ain't nuthin'! My wife is dumber than both yer wifes put together! I was going through her purse the other day lookin' fer some change, and I found 6 condoms in thar.'
Hillbillies 1 & 2 say: 'Well, what's so dumb about that?'
3rd Hillbilly says: 'She ain't got no pecker.'

________________________________________

"Never take a sleeping pill and a laxative at the same time !!!!!!"

 

[seahawk188]

I read from somewhere if you do a cross-over, you don't need to pay too much attention to other pts you don't owned, except for life or death situations or other critical conditions. Is that sound advice? I assume during cross-over you are going to see a tons of pts.

 

[SouthernSurgeon]

I read from somewhere if you do a cross-over, you don't need to pay too much attention to other pts you don't owned, except for life or death situations or other critical conditions. Is that sound advice? I assume during cross-over you are going to see a tons of pts.

It's cross-cover, not cross-over.

And the bolded statement scares me, frankly. When you are cross-covering, you OWN every patient. You pay attention to each one dependent on their current clinical status.

 

[gutonc]

I read from somewhere if you do a cross-over, you don't need to pay too much attention to other pts you don't owned, except for life or death situations or other critical conditions. Is that sound advice? I assume during cross-over you are going to see a tons of pts.

Outside of the ICU, cross cover just means you're the one that gets called if something needs to happen/goes wrong on a patient. This can range from a K of 3.4 to a code. Some things will require you to see and evaluate the patient (and until about December, pretty much everything should make you go see the patient), others will just require an order. It's not like you're rounding on them all, examining them and writing notes.

Personally, in the ICU/CCU, when I was on NF and cross-cover, I always at least did hallway rounds with the fellow at the beginning of the shift.

 

[seahawk188]

It's cross-cover, not cross-over.

And the bolded statement scares me, frankly. When you are cross-covering, you OWN every patient. You pay attention to each one dependent on their current clinical status.

Thanks for the correction! I have been out of medical field too long thus the ignorance!

I guess "pay attention" is not a right phase here. What I mean is do you treat your own pts and cross-cover pts absolutely the same? If you need to cross cover 70-80 pts, how can you find time to do it?

 

[seahawk188]

Outside of the ICU, cross cover just means you're the one that gets called if something needs to happen/goes wrong on a patient. This can range from a K of 3.4 to a code. Some things will require you to see and evaluate the patient (and until about December, pretty much everything should make you go see the patient), others will just require an order. It's not like you're rounding on them all, examining them and writing notes.

Personally, in the ICU/CCU, when I was on NF and cross-cover, I always at least did hallway rounds with the fellow at the beginning of the shift.

This sounds more like it!

So what is exactly the difference between NF and CC?

 

[gutonc]

This sounds more like it!

So what is exactly the difference between NF and CC?

Night Float is a dedicated, night shift that (usually) does cross-cover and admitting. Cross-cover just means that you're responsible for all the patients on your service (whatever that may be). If you have a traditional overnight call system, you will likely still cross-cover all the other patients on your service (IM, FM, Peds, Gen Surg, whatever). There are exceptions to this of course but that's the gist of it.

 

[seahawk188]

Night Float is a dedicated, night shift that (usually) does cross-cover and admitting. Cross-cover just means that you're responsible for all the patients on your service (whatever that may be). If you have a traditional overnight call system, you will likely still cross-cover all the other patients on your service (IM, FM, Peds, Gen Surg, whatever). There are exceptions to this of course but that's the gist of it.

Thanks for the clarification! It's hard to grip it first, but after reading a few more times, I stopped scratching my head!

I have read a lot of horrible stories about interns buried under tons of paperwork. Is it still norm those days? If your system has EMR, will it help?

 

[smq123]

I have read a lot of horrible stories about interns buried under tons of paperwork. Is it still norm those days? If your system has EMR, will it help?

Hah, no. EMR just takes the physical "paper" out of paperwork; it doesn't make it go away or really speed it up all that much.

 

[seahawk188]

Hah, no. EMR just takes the physical "paper" out of paperwork; it doesn't make it go away or really speed it up all that much.

It doesn't make you more efficient? First, I thought typing is much speedier than handwriting. Second, if you have all the preorders in the EMR and you just need to put in a check mark, doesn't it save work?

 

[smq123]

It doesn't make you more efficient? First, I thought typing is much speedier than handwriting. Second, if you have all the preorders in the EMR and you just need to put in a check mark, doesn't it save work?

It depends on the system and on your hospital.

- Our hospital is switching to EMR, and sure, they have order sets....except that, if I want to consult a specialty, I have to NAME the specialist - I can't just consult a service. Which, if I don't know who the individual endocrinologists at the hospital are, means that I have to go find someone, ask who an endocrinologist is, and then put in a consult for that person.

- Searching for the exact lab test you want isn't always intuitive. For our system, it's listed as "Count - Blood, Complete" or something equally awkward.

- If you have an unusual order, trying to put that into the computer system takes up all the time you saved by typing or using the pre-made order sets. For instance, the people who devised our EMR system were unaware that children can have DKA as well , and need very unusual and specific IVF orders. Those IVF orders, however, have to be manually put in, at least until someone makes up an order set for those....which will happen sometime in the next decade, I'm guessing.

Eventually, it probably DOES make you somewhat more efficient, but it takes a while for the benefits to be realized.

 

[Flopotomist]

It doesn't make you more efficient? First, I thought typing is much speedier than handwriting. Second, if you have all the preorders in the EMR and you just need to put in a check mark, doesn't it save work?

The problems with EMRs are that as the ease of documentation increased, the expectations of what is to be documented also increased for a sum total of no time saved. Often, you spend time copying and pasting information from one part of the EMR (eg vitals, labs etc) to another part of the EMR. It drives me nuts.

 

[seahawk188]

....except that, if I want to consult a specialty, I have to NAME the specialist - I can't just consult a service. Which, if I don't know who the individual endocrinologists at the hospital are, means that I have to go find someone, ask who an endocrinologist is, and then put in a consult for that person.
..

Don't you need to do that even if you don't have EMR?

 

[seahawk188]

The problems with EMRs are that as the ease of documentation increased, the expectations of what is to be documented also increased for a sum total of no time saved. Often, you spend time copying and pasting information from one part of the EMR (eg vitals, labs etc) to another part of the EMR. It drives me nuts.

So EMRs are still not smart yet, will it get smarter later on?

I guess mastering EMRs has a steep learning curve too.

BTW, I enjoy your supersquirrel avatar!!! I hope I will be as half happy as she/he is at the end of my internship!

 

[MattD]

Don't you need to do that even if you don't have EMR?

I thought the same thing. Even if you CAN request a consult with a simple computer order, I think it would be pretty rude to call a consult without actually CALLING the consultant (or service-specific resident).