Currently a prelim, how do I get same OR time as my catagorical intern?

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IRorBustguy

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I started a residency program in the SE this past week and I'm heading into IR. My team is great and my categorical co-intern and chief are all great, but it seems like whenever there is an intern appropriate case, my co-intern gets to go do it. He's even let me know that he has no problem splitting cases with me and I've expressed interest multiple times to my chief (who also seems to like me) that I want to operate as much as possible, but every single time my co-intern is called to do it. And I'm just sitting around managing the floors. Any suggestions?

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Not sure what to tell you. The categorical intern it's going to get preferential treatment at the expense of the guy going into IR. As a former prelim I feel your pain.
 
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I started a residency program in the SE this past week and I'm heading into IR. My team is great and my categorical co-intern and chief are all great, but it seems like whenever there is an intern appropriate case, my co-intern gets to go do it. He's even let me know that he has no problem splitting cases with me and I've expressed interest multiple times to my chief (who also seems to like me) that I want to operate as much as possible, but every single time my co-intern is called to do it. And I'm just sitting around managing the floors. Any suggestions?
I can see how that would be frustrating for you. Most programs will try and make sure that things are pretty equal for the pre-lim interns. However. Pompacil is correct: the program has invested in the categorical resident for at least five years so in almost all cases if there is a choice they will be it.

Furthermore, many prelims not going into surgery have little to no interest being in the OR so your senior residents may be making an assumption that is not true for you. Id say it's too early to tell whether this is something that's going to be a pattern for the next year.

While we all know that being in the OR is fun, I suggest that perhaps you re-think what it will do for you and how it will meet your goals. Several of your colleagues talk about places where IR admits their own patients and how this is the wave of the future. It gives the rest of us angina because we've seen how poorly managed these patients are because of the lack of knowledge about basic periprocedural care ( things like putting patients on a diet once they're stable, giving fluids etc. ). therefore why not embrace your time on the floor to learn about common perioperative problems, how there are managed, and just basic things to take good care of people after they've been sedated or under GA. . Those are things that your colleagues going IR who don't do a surgical preliminary year will have a good handle on. Youll have plenty of time to learn how to do interventional procedures but you've only got one year now to learn how to take care of those patients before and after your intervention. Why not embrace that?
 
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Most programs really do make a concerted effort to make sure there is a fair distribution of cases between prelims and categoricals. There are some programs where you'll be treated differently and you will get the short end of the stick if you happen to be at one.

It's only a year and not what you're going to do with your life. I'd suggest you learn what you can, where you can and then move into your real residency. There isn't a huge potential gain for you in turning this into a big issue and there are potential pitfalls.


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A week in and there is discussion of the OR? Wow. My very academic intern year was all about floors and a couple of cases here or there. No cases much for us to even fight over
 
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I can see how that would be frustrating for you. Most programs will try and make sure that things are pretty equal for the pre-lim interns. However. Pompacil is correct: the program has invested in the categorical resident for at least five years so in almost all cases if there is a choice they will be it.

Furthermore, many prelims not going into surgery have little to no interest being in the OR so your senior residents may be making an assumption that is not true for you. Id say it's too early to tell whether this is something that's going to be a pattern for the next year.

While we all know that being in the OR is fun, I suggest that perhaps you re-think what it will do for you and how it will meet your goals. Several of your colleagues talk about places where IR admits their own patients and how this is the wave of the future. It gives the rest of us angina because we've seen how poorly managed these patients are because of the lack of knowledge about basic periprocedural care ( things like putting patients on a diet once they're stable, giving fluids etc. ). therefore why not embrace your time on the floor to learn about common perioperative problems, how there are managed, and just basic things to take good care of people after they've been sedated or under GA. . Those are things that your colleagues going IR who don't do a surgical preliminary year will have a good handle on. Youll have plenty of time to learn how to do interventional procedures but you've only got one year now to learn how to take care of those patients before and after your intervention. Why not embrace that?


Hm....you know, I think this a very reasonable way of putting things. You are right, a lot of the IRs have no idea how to manage their admitted patients. Technical skills will come with time and practice. I think its more a matter of having equal expectations and equal treatment though.
 
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Hm....you know, I think this a very reasonable way of putting things. You are right, a lot of the IRs have no idea how to manage their admitted patients. Technical skills will come with time and practice. I think its more a matter of having equal expectations and equal treatment though.

Fair enough.

As others have noted above, its very early and other Chiefs/senior residents/attendings may make things more uniform between the categoricals and prelims in your program when you are on their services.

Or they may not because, as I noted, the program is more invested in the categoricals and have a short 5 years to see that they're trained well.

Best of luck to you; I hope it works out.
 
I think the OP needs to make it known that he/she is interested going to the OR, even though the ultimate plan is to do IR.

In my program, we had interns that planned to go into EM or straight diagnostic radiology who had no interest in operating and those people did just take care of the floor duties and answer pages. When I was chief and one of those people was on my service, I would find a categorical or someone around on another service that wanted to do the case and give the call pager to the non-op prelim with no interest in the OR.

We had family medicine residents rotate with us also and we would definitely get those guys into the intern lumps and bumps.

And if I just liked my intern and thought they were hardworking, I would get them to come to the OR regardless of operative interest.

So I guess YMMV.
 
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If I were you, I would aggressively learn how to manage the patients on the floor. Forget about the OR. You won't be there to operate.

People like us need to learn the art of periprocedural care well if there is any hope to reclaim our turf.
 

Procedures like PAD or aortic work. As you know, leaders of IR previously advocated sharing of technical knowledge with vascular surgery with the hope of working together to benefit patients.

The reality, in most institutions, did not pan out this way as IRs are all but shut off completely from PAD work. I was told that some instrumental person in development of aortic stent graft has recently lost their OR priviledge for EVAR.

I actually firmly believe that endovascular PAD work is a must have for vascular surgery because lack of such spells the death of their field, and I am not arguing for IR "take back" PAD completely, but rather develop enough competitive clinical acumen to share the pie that is PAD.

I do think, however, many conditions that previously required surgery in the acute setting (such as certain type of cholecysitis) no longer require surgery in the inpatient setting accordig to some guidelines but rather interventional treatment, and those patients should be admitted to the IR service. One of my plan as an attending would be to offer off hour admission of certain previously surgical diseases that are now days mostly managed inpatient by IR in order to relieve the pressure off my surgical colleages. I will of course coordinate their elective surgical referal when they are discharged.

I am not the only IR person who think like this. There are many of us, who think like a surgeon, trained with surgeons, and are ready to work like a surgeon to gain clinical acumen needed to manage our patients. I am even married to a surgeon, and I have a lot of respect for their sacrifice.

For example, when she was an intern, she woke up everyday at 4am, went home at 7-8pm and fell asleep next to me routinely. As IR physicians, we MUST be prepared to work this hard, or have junior residents who will work this hard to provide a clinical availability comparable to a surgical service

That's reality of what it takes to claim a "turf". Now I tell all my juniors that if they want PAD, they must work to demostrate they are capable to cover a clinical service as well as our surgical colleagues.

To the OP, as an intern you should be prepared for the eventuality of providing your own clinical management. IR isn't surgery, but it isn't radiology or medicine either. It's something in between.

Again, it's mostly useless for you to learn how to cut because our job isn't to cut. You must learn how to work in a clinic and the floor, however.

P.S. My wife always joke about how I want to steal her job or how she's in bed with the enemy, but I truly believe the best patient care can only be achieved through different services working together, with IR's presence being a must in many emerging indications.

Angiography skills stem from understanding of imaging basis of human anatomy, and are almost completely different from surgical skills.
 
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Just wow. I don't have any problem with IR doing PAD work, but IR doing PAD work without vascular surgery is a joke - while the inverse is not. You have no way of fixing your screw ups or disease progression etc. etc. etc. vascular surgeons can do the endovascular treatment and if it progresses the open surgery as well. And if that progresses the amputation.

If you think the treatment of cholecystitis is going through a paradigm shift that involves admission to an IR service, cholecystostomy tube or something like that - then I'd like some of whatever you're smoking. The treatment of uncomplicated cholecystitis is cholecystectomy. The treatment of complicated cholecystitis will likely remain a tube - but these patients are sick enough that there are 0 IR docs I know who I would want managing the patient (regardless of an intern year in surgery).

Additionally, off hour admissions for a surgical service? What a joke. Getting an IR to come into the hospital for a true emergency is already pulling teeth. Getting them to come in for an h&p or to manage a sick patient who doesn't need an IT procedure - it's just so far beyond the realm of realistic that it's laughable.


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Just wow. I don't have any problem with IR doing PAD work, but IR doing PAD work without vascular surgery is a joke - while the inverse is not. You have no way of fixing your screw ups or disease progression etc. etc. etc. vascular surgeons can do the endovascular treatment and if it progresses the open surgery as well. And if that progresses the amputation.

If you think the treatment of cholecystitis is going through a paradigm shift that involves admission to an IR service, cholecystostomy tube or something like that - then I'd like some of whatever you're smoking. The treatment of uncomplicated cholecystitis is cholecystectomy. The treatment of complicated cholecystitis will likely remain a tube - but these patients are sick enough that there are 0 IR docs I know who I would want managing the patient (regardless of an intern year in surgery).

Additionally, off hour admissions for a surgical service? What a joke. Getting an IR to come into the hospital for a true emergency is already pulling teeth. Getting them to come in for an h&p or to manage a sick patient who doesn't need an IT procedure - it's just so far beyond the realm of realistic that it's laughable.


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I sense a lot of lack of respect for what we do, which is tragic, because we have a lot of respect for what you do.

Note that I did not advocate at all for IR to do PAD alone.

Note that my post is about a new breed of IR physicians who are more than happy to come in and share YOUR burden.

I honestly don't care how YOU want to manage cholecystitis or other conditions. I care about how the current evidence about cholecystitis management, and you can bet that myself and others will manage IR related diseasea and conditions to the best of our ability.

If someone is admitted to my service, they are admitted under an IR service. I am NOT a surgeon. I never pretended to be one, and my service is NOT a surgical service. However, if certain diseases aren't even treated with inpatient surgery by current evidence, why should they go to a surgical service?

At the end of the day, it's regretable that you had unfavorable experiences with IR. I personally had extremely unfavorable experiences with surgical trainees. One of the surgical chief asked me to drain a fresh bowel anastomic leak that was draining frank stool (evidently they did not run it by their attending), etc. I find it extremely ironic to have to remind this person some basic surgical tenets. Again, lack of knowledge or professionalism isn't marked by the title one wear.

Ultimately, patient care must come first and we must work together to achieve a better outcome.

And for rest of the students interested in IR. Do a surgical internship and learn as much periprocedural management that you can.

Lastly, I am not sure if this discussion is entirely on topic or still within the perview of this surgical subforum. I will be more than happy to drop this conversation if it isn't a welcomed one here.
 
I have plenty of respect for IR. They've rescued me more times than I can count. I've had very few unfavorable experiences with IR, don't place words in my post.

What I don't have respect for is people who think they have expertise which they don't (especially when it will result in harm to patients). Thinking that any appreciable number of IR attending are capable of running a service with complex admissions with surgical problems is a joke - especially those that think they can do it after 1 year of prelim surgery.

You say patient care must come first, but are advocating for providers with less clinical experience take care of problems in which they would clearly be out of their depth.

One year of internship in surgery does not qualify you to take care of complex surgical admissions, manage floor patients or run an inpatient service. It qualifies you to go onto your IR residency.


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One of the surgical chief asked me to drain a fresh bowel anastomic leak that was draining frank stool (evidently they did not run it by their attending), etc. I find it extremely ironic to have to remind this person some basic surgical tenets.

I'm Ortho, and that sounds wrong even to me.
 
I'm Ortho, and that sounds wrong even to me.

This person just graduated this year....somehow the big wigs in the surgery department convinced them to do a subspecialty away from the GI tract
Meh, sometimes the devil is in the details. We had a complex patient with a bad bad leak. My staff was pretty experienced but ended up conferring with about 5 of the other attendings in his group, including the dept chair and two of the "senior statesmen". Consensus from all was attempt perc drainage...and if that failed...attempt perc drainage again.

The IR fellow in that case tried to "remind us of some basic surgical tenets". It went over real well.

Could you enlighten me on the reasoning of that? I am very interesting to hear! I hope I wasn't being ignorant that day. (Patient went into the OR in my case).
 
In many cases you can't simply just go in and "fix" a leak. Sometimes you end up just accomplishing the same thing IR does (drainage), but via a laparotomy. Sometimes that's preferable as you can also wash them out or lay multiple drains and theoretically achieve better source control. Sometimes for a distal leak you can divert them.

Sometimes though, the additional physiologic hit of a second operation is more than a patient can take, particularly if you have no reasonable belief that you will be able to definitively manage the leak.

Timeframe from operation, nature of leak (location, volume, systemic response), and patient factors all play a part in the decision.

Appreciate the education! What type of questions should I ask in the future in order to tease out if a request for this is an error or a thought out response beside "have your attending looked at it yet?"
 
Appreciate the education! What type of questions should I ask in the future in order to tease out if a request for this is an error or a thought out response beside "have your attending looked at it yet?"

You can always word it differently. I think a professional and collegial way to handle any situation is "Hi _____, good to hear from you. Always happy to help you guys out. This is an unusual situation, can you tell me a little more about it for my education since I know you guys usually reoperate on leaks?"

Then you don't sound like you're questioning their surgical judgment and you get the education you're looking for.
 
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