Help! I'm not liking my program

[supercut]

I know it's early, but each day I have an increasing feeling that I don't like the program and don't want to stay here. There are several things that I have learned since coming here that, had I known about, would have caused me to rank the program much lower (or perhaps not at all). Each thing individually might not be enough to make me think this way, but the total package has me thinking I made a huge mistake.

I went to school at a place where the residents have a lot of autonomy, and acutally do most of the cases. The upper levels take the lower levels through cases, with the attending making a brief appearance. I acutally did quite a bit in the OR as a student. There is also tons of ICU exposure were I went to school, starting in first year.

My current program has no ICU exposure in the first year. Right now I'm on a specialty service with fellows, so there's not much OR time (and I don't expect it). However, there have been a few intern appropriate cases (or cases that are approprate for an intern to do some of). When I scrubbed these cases, I was not allowed to do anything. In fact, I was not even allowed to operate the stapler for closing skin. Plus there are PA's for most services and the PA's run the floor and tell the interns what to do. Attendings often round with the PAs when we are in conference. The PA don't let the interns present the pts if we happen to be around for rounds. Interns are usually sent to do things the PA don't want to do. PA's make all the pt managment decisions and send interns to take out staples, pull drains and change dressings. The floor nurses ignore the interns, addressing all questions to the PA. There are also RN first assistants who do things in the OR that the intern otherwise would on the bigger cases. I asked if they would teach me and they said no. I only get to do stuff if they decide they don't want to (like if one wants to leave early, they might let me suture skin) It's worse than being a med student.

I don't know how to go about looking for a PGY 2 slot when the time comes. Is there a list on the web? Also, I'm afraid that if I found a slot in a program I like better, I'll be so far behind my counterparts that maybe I should go through the match again and repeat intern year at a program where I will learn something?

I hate that I already dread getting up and going to work. I know it's not surgery that I don't like, it's the program. I actually prefer being on call becuase then I don't have to deal with the PAs

I'm open to advice!

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[DuneHog]

Wow, it definately sounds like you should change programs. Residency is hard enough and it's not worth it if you aren't even getting good training. Have you talked to the senior residents? Do they feel prepared to go out and practice?

I'm assuming your doing general surgery. If so, I don't think you should have a problem finding a vacant PGY-2 slot if your not picky about location. Just because of the sheer number of general surgery positions there are bound to be some openings. That combined with the fact that there are plenty of people who start general surgery and don't like it/can't hack it. From what I've heard, you basically have to talk to your PD and get his/her blessing. Then you can go about looking for openings. The best way to approach it would be to find reasons why the program is not "right for you," so as not to insult the program and program director. Once you have your PD on your side, you can begin your search.

I'm guessing that you are at a community program, probably in a nicer part of town. I would suggest that you look for an inner-city program at a public, VA or university affiliated hospital that has larger underserved population. This is where you will get the kind of training/exposure you're looking for. Although I interviewed for ENT, I found that there are certain programs that have a repution for a lot of resident autonomy. These were at hospitals like USC-County, Grady, Cook County and programs in rough inner city areas, like the Bronx, Brooklyn, Detroit etc. Best of luck to you. I hope you find what you are looking for.

 

[MacGyver]

PAs running the show and dictating things to residents is outrageous. Sounds like your hospital is very poorly run.

A busy hospital should be staffed so that there is little competition between RNs, PAs, and MD residents for patients. The fact that your hospital pits you guys against each other makes me wonder why that hospital has a residency training program to begin with.

Usually, hospitals need residency training programs to handle the patient load--but apparently that isnt the case at your program because they obviously have the PAs and RNs do everything important.

Therefore, I am betting that the ONLY reason this hospital has a residency program at all is because its free $$$ from Medicare (at 100k per year per resident). This is scandalous--the only hospitals who should have residency programs are those that need the residents to take care of patients. Since you have a minimal role in that aspect, that tells me that this particular hospital doesnt really give a damn about training residents and just wants the $$$ that comes with the residency program courtesy of Uncle Sam.

Medical residents should receive the priority for training after fellows and senior residents. The fact that PAs get to do everything is totally backwards from the way things are supposed to run. If there is so little patient demand that PAs compete directly with MD residents, then something is very wrong at that hospital.

 

[mpp]

Just to clarify on Mac's comment regarding medicare payment for residents. Stating a $100,000 per resident payment is an oversimiplification of the Medicare reimbursements for graduate medical education. The payment for graduate medical education comes from medicare in two forms...direct and indirect payments.

Direct payment to a teaching hospital is determined by a per resident amount multiplied by the fraction of hospital inpatient days that are paid by Medicare. The national average per resident amount for this year is $77,184 (which is adjusted by a few factors including direct costs (salary, benefits, overhead, etc.) and location but typically does not exceed $100,000). Note that the this number is still multipled by the faction of hospital inpatient days that are paid by Medicare which can vary drastically from hospital to hospital.

The indirect payment is an adjustment to the normal Medicare patient payments to the hospital. The amount of the adjustment is determined by the intern- and resident-to-bed ratio (IRB). The current formulat to determine the IME adjustment is ((1+IRB)^.405-1)*1.66 . If the IRB is around .1 (i.e., 1 resident for every 10 beds) the IME adjustment is about 6.5%. If the IRB is around .5 (i.e, 5 residents for every 10 beds) the IME adjustment is about 27%. So the total IME payment also varies drastically depending on the IRB and how much the hospital bills Medicare for patient services.

Medicare payment for graduate medical education are only paid for the number of years for which the ACGME required for each specialty. (For example, if you do internal medicine they will only pay for 3 years...even if you go on to subspecialize and are in a fellowship for several more years). Medicare does pay 50% of the direct payment however for your years after your initial residency.

The Medicare payments to a hospital is dependent on many factors and you cannot just say that hospitals receive X amount of dollars per resident. If you want to come up with a 'per resident' amount it would be best to take total Medicare expenditure and divide it by the total number of residents. For the year 2000 this would be approximately

$7,900,000,000 / 96,410 residents for a total of $81,941 per resident. There is some additional income from individual states and the VA program that is not accounted for which may bring the numbers up to near $100,000 per resident. But keep in mind that this pays for the resident salary + benefits + additional cost of the teaching physician salaries and isn't the great windfall for hospitals that it might seem on the surface. Plus, residents tend to be more 'wasteful' in terms of patient care due to their learning and total per patient income has been found to be lower in teaching hospitals than in non. Furthermore, because of the formula used for the IME, increasing the number of residents does not directly increase IME income...it is not a linear relationship.

Sorry, this has nothing to do with the original post but I've seen this '$100k per resident' figure thrown around so much that I just wanted to clarify it.

 

[supercut]

Actually, I'm at a university program, where there are some rather well known faculty. I won't divulge any further.

Some services are worse than others, and I'm currently on one of the worst. But talking to some of my fellow interns who went to school here and know the ropes better, I hear that there is one service on which the PA tells the intern to go away (off the floor)...go read, go take nap, go to the OR (but basically just go away). There is another service where each attending has his/her assigned PA for just his/her pts and they don't communicate well with the interns.

The upper levels acknowlege a problem with PA's on some services. All feel like they are getting good training. The highest on my service right now is R3, so I can't really observe the skills of a chief this month. And just becuase they say they feel they are getting good training doesn't mean that they are getting the kind of training I want. I did an away elective as a student (at a different program) and the chiefs who said they felt well trained weren't up to the level of the avearge R4 at my school. (I didn't stay put because the program there is pretty malignant and I also believe variety in the different levels of training is a good thing)

Here is one concern I have: let's say I find a pgy2 slot at a place that suits what I want better. Such a place would have interns in the ICU. But not having done any ICU time in my intern year (and not done much independent managment of anything), how could I possibly help next year's interns as a PGY2 with no ICU experience? That's why I wonder if I might need to repeat PGY1 as much as that would suck.

 

[Foxxy Cleopatra]

Hi supercut-

I am sorry to hear that you are not having a good experience at your program. That pretty much sucks. I was afraid of what I was getting myself into when I came here (I really started to question my judgement of ranking places highly that I only saw on a single interview day.) Luckily, it's pretty good for the most part- you get your days where you are tired and sick of social work issues, but they do let me operate and are a pretty good bunch of guys.

Will you spend any months at all as unit boy at the place where you are now? Any chance that you may rotate through a hospital where you will have more autonomy? I have to say, though I have had a great time operating here, probably 80% of what I do is paperwork or other non-academic work; in other words, many programs you do so much scut as an intern you may not be far behind the rest of us after this year. I don't know, maybe if you do a lot of reading up you may feel more comfortable transitioning into a PGY-2 spot.

A guy in my intern class was at another program where he wasn't happy and transferred here (so lost 1 year of time.) Though he isn't thrilled about doing 2 PGY-1 years, he looks very experienced compared to the rest of us.

Wish I had better advice but just wanted to say you have my condolences, especially knowing how I could be in those shoes.

good luck
-f.c.

 

[hemoccult]

I know it wouldn't be the most appropriate thing to do, but if you could somehow convey your general location in the country and/or private message an applicant to general surgery regarding your program, this kind of information would be greatly appreciated. I don't want to cause you any more pain than you are apparently going through currently.

Also, where did you go to school? From what you describe, your school's surgery program allowed for excellent autonomy as a resident.

In retrospect, is there anything you could have done to discover then what you are now finding out?

I wish you the best in your difficult situation. I can only imagine your dilemma and it is only the first month of residency. As a consolation, perhaps, maybe future months will come with more autonomy.

Take care

 

[FliteSurgn]

I'm sympathetic to your situation, but in your first month of internship how much autonomy do you think that you deserve?

I happen to have had a similar experience in my internship regarding ICU exposure. The surgery service got medical ICU consults on every ICU patient. At the end of my internship, I know that I didn't even know how to write for vent settings and I don't think that the chiefs knew much about ICU management either.

Fast forward through 2 years of military service and I was back looking for a GS residency. From sheer luck, I managed to attain a PGY-2 spot at a great program where the residents get a TON of ICU and operative experience. I was nervous about how far behind the curve I would be given my history, but my fears subsided and I ended up growing in knowledge and experience swiftly.

I would start by talking to your program director. Most of the PDs that I have known have been pretty easy to approach. Let him know your concerns and see what he has to say. After that reassess your situation, commitment to surgery, desires, etc. If the only apparent problem is that you can't tolerate your current training locale (give it a few more months to know for sure), I think that you are better served by looking elsewhere either at the intern or PGY-2 level. Don't let your inexperience as an intern lock you out of PGY-2 spots. If the place you end up has good experience, staff, and residents then they will gladly get you up to speed. I can testify to that!

 

[MacGyver]

Originally posted by mpp
But keep in mind that this pays for the resident salary + benefits + additional cost of the teaching physician salaries and isn't the great windfall for hospitals that it might seem on the surface. Plus, residents tend to be more 'wasteful' in terms of patient care due to their learning and total per patient income has been found to be lower in teaching hospitals than in non.

Its all relative. Compared to hiring a PA at 70k per year out of their own pocket, or hiring an MD/DO attending at 130k, residents make financial sense for hospitals.

The number of residency slots has increased dramatically over the past 20 years, far outpacing population growth.

Furthermore, this increase in residency slots has come at the request of hospitals, not the ACGME or other accrediting agencies.

If hiring residents was such a financial burden on hospitals, how do you explain the sharp increase in overall residency slots? The bottom line is that hospitals make money off their residents and use it to subsidize the expenditures that go out to non-insured patients.

 

[supercut]

Thanks, folks. And I defintely plan on giving it some more time, but I also have to start thinking about what to do. If I decide to go thru the match again, there isn't much time to waste.

I really don't think I'm expecting inappropriate autonomy as an intern. I expect to be allowed to manage the floor issues with input from upper levels as appropriate (eg pt can't poop, is nausated, has incresed bp, etc). This is not happening. The PAs do all that. They stay on the floor all day, and send me to change dressings, take out staples, etc, or to do admission paperwork. I expect to do all of these things as an intern, but I did not expect to have PAs managing the floor issues and being unwilling to let me do so. Interns do not set foot in the ICU here. I won't do any lines or other procedures like that this year. Plus the few intern level cases I have scrubbed I have done nothing. My hands never touched an instrument.

Most of the residents seem pretty happy here. But them I think that most of them went to school at places where they didn't do much as students so coming here wasn't a step down. For me it is...I am much less involved in patient care here as an intern than I was as a student. I'm afraid I will loose the skills I had acquired as a student.

The program I went to school at does have a lot of resident autonomy and interns do several months in the ICU, and are comfortable enough with lined, bronchs, etc to give them to students pretty early on. Also I DID cases that were more involved than the ones I have been not allowed to do as an intern. I didn't stay for personal reasons, and now I'm thinking I made a huge mistake, because that was the kind of program I wanted.

What would I do different? I liked this program a lot and got great vibes during interviews. One problem was that I emailed the secretary and asked her for a sample schedule. She told me that she didn't have that information. She finally sent it to me....after the ROL deadline. So I wish I had ranked the program lower for failure to answer my questions.

Current M4's: be sure to ask if the programs use PAs and what the role is. DOn't ask the faculty, ask the residents

So let's say I make the decsion to look for a pgy 2 slot. When should I let my PD know? How do I find out about open PGY 2 slots?

 

[droliver]

I think this (your disatisfaction with your role) is something you need to take up with your PD. Being the PA's gopher is not the way things were envisioned when allied health providers were proposed to be introduced more by the ACGME & RRC in surgery. The PA's or NP's should be doing those chores in order to free you up, not vice versa. Do others feel the same way you do at your program? This sounds like a terrible,terrible training program you've jumped into if this representative of the philosophy of your program. BTW is this a community or university based system?

 

[supercut]

It's a UNIVERSITY program. And the frustration with PA is a source of constant conversation in the resident lounge. The service I am currently on is one of the worst. To be fair, the PA's do take care of most of the dicharge paperwork, social work, follow up appointments, etc. But in a way I feel they are doing a little to much because I still can't dictate a coherent discharge summary they do so much of it. Occaisionally I dicharge a pt on the weekend and they have done an interim dishcharge summary up to a day or two before discharge date. (I know it's a weird complaint that I'm not doing enough paperwork, but there are some rotations here that don't have PA's yet and I'd like to be able to be efficient when I start those)

Anyway, the PA on my current service clearly don't like it when the resident puts in any orders into the computer system. Often the labs aren't back before the residents have conferece, so when the PAs arrive, first thing they do is look at the labs write orders for anything that needs doing from that. If I put any orders in the system before the get there, often they are changed by the PA. Then they start the paperwork. I come back from conference, they send me to do dressings, take out staples, etc. Then they start getting notifiied of admissions so they send me to do the admission paperwork. Meanwhile, they stay on the floor and the nurses take all the concerns to the PA and they manage all the problems (even when I am on the floor, the nurses go to the PA for anything from can Mr X ambulate to Mr Y is having chest pain...they completely ignore me. If the PA's are at lunch, and I'm on the floor, the nurses come to me to ask where the PA's are so they can bring pt management issues to the PAs) Sometimes I get to go to the OR to help with a small part of a big case, but that really happens only when the RN first assistant doesn't want to.

Don't get me wrong, I EXPECT to do dressing changes and admission paperwork. What I do not expect is to be excluded from the routine pt management. I'm even excluded from rounds...the attendings round with the PA's. If I'm on the floor and notice that the attending is there to round, I show up. But usually the attending addresses the PA's, not me. I'm told that this will happen on my next service as well. (In fact, one of the PGY 2 told me that those PA told him when he was an intern that they run the service and he is to report to them.)

So it is problematic here, though I don't think anyone else is or has been unhappy enough with the situation to consider leaving. I am. When I talk to the my counterparts I went to school with who are at other programs, I see that I am rapidly falling behind in skills.

Residency is supposed to be OJT and when you don't get to do anything, you don't get to learn. That's why I'm not sure if I should just try to go through the match again or try to look for an open slot next year. I'm afraid I'll have been coddled so much that I won't be able to function as a PGY 2 at another program.

 

[droliver]

I would really get as far away from the program you're describing as you can. It sounds like your attendings have sacrificed your training for their convenience in re to the PA situation & the RN-assistant in the OR. This is a much bigger issue and really needs more attention then your predecessors apparently have given it. I would try to get some unified front with your other residents (or chief administrative resident) and take your concerns to your program director

 

[ArrogantSurgeon]

Sounds like the PAs at your program think they went to medical school and are actually doctors. I have to deal with that kind of garbage too as a MS4 and realize how annoying it can get when PAs overstep their role.

I agree with what has been said here about ditching this program and going to one where MDs are trained and treated more accordingly.

And if you don't mind, PM me the name of this program so that I don't have to bother considering it for residency. Good luck.

 

[Chode]

Originally posted by ArrogantSurgeon
Sounds like the PAs at your program think they went to medical school and are actually doctors. I have to deal with that kind of garbage too as a MS4 and realize how annoying it can get when PAs overstep their role.

I agree with what has been said here about ditching this program and going to one where MDs are trained and treated more accordingly.

And if you don't mind, PM me the name of this program so that I don't have to bother considering it for residency. Good luck.

hey, arrogant STUDENT:

You forget that most PA's are service extenders for your attendings. These PA's make $$$$ for your surgeons group. They are hand picked and personally trained.

Therefore, they are more valuable and most times have more influence than you ever will as a student or resident. They do not work for you. When you speak to them , you are actually speaking to their boss.

They own you, with a lot less training!

That bugs you doesn't it?

God created MS4's and interns to manually disimpact old ladies, do dressing changes, and chase down labs.
that's it

 

[unregistered]

Your situation sounds bad and perhaps the PAs aren't letting you do too much....

But, this scenario seems like the future to me, especially in re to the 80-hr rule.

You prolly don't work more than 80 hr. As hospitals find the need to hire more PAs and RNs it seems like this scenario will be more prevalent....

...just a suposition from a future surgeon to be.

 

[Winged Scapula]

Wow...I'm not even sure what to say.

If it is indeed true that you are working as the PAs lackey and your education is suffering, then you need to have a serious talk with your PD and/or consider cutting bait and starting over.

If the "trouble with the PAs" is a favorite topic amongst the residents, perhaps a group meeting with the PD and the faculty is in order.

PAs are supposed to be physicians extenders, people who work with you, to help you gain the training you are there to receive...you should not be spending an inordinate amount of time taking orders from them, taking out staples and the like. The educational use of that is minimal after the 400th staple you've removed. It sounds as if the attendings are not doing much to help everyone realize their role on the team...there is nothing wrong with the PAs rounding with the attendings - as it stands, it sounds as if they know more about what's going on with the patients than the residents do. However, you should be included and asked to take part in the day to day management of your patients while also getting to the OR.

One of the problems I see facing you is a lack of valuable surgical/medical experience. I found myself behind the 8-ball as a resident because I wasn't "aggressive" enough - that is, I didn't seek out lines to do or other bedside procedures. This became a problem as I became a 2nd year as I was expected to teach the interns - if you've got others doing your lines, putting in chest tubes, removing them, getting ICU experience, and managing the patients, how will you be expected to perform those duties, let alone teach someone else how to do them?

There are other programs which are not heavy on ICU experience - mine was the opposite. I'm currently rotating at a local community hospital, doing lots of surgery, but intensivists and medical groups are consulted on all of our patients - I'm forgetting how to manage a vent (as if I ever really knew it well). I'm sure if you came in as a second year at another program you would pick up the knowledge you need at a good rate.

Is it possible at your current program to spend some extra time (I know, who wants to?) and see if the critical care docs will take you through lines, call you if one needs to be done, etc? Perhaps if you show them some interest you can bypass the PAs and get the experience you crave and DESERVE.

If your program is unwilling to change and provide you with the education it promised, I'd say you need to find another place for next year and beyond.


Best of luck...

 

[fourthyear]

What a nightmare! If I were you, supercuts, I'd transfer even if it meant doing another intern year. I mean, this is your whole future all wrapped up in 5 years of training - what's one more year repeated if it saves you a career full of problems b/c you did a residency where you learned nothing?

I don't see it possible to change the program from within, since it's obvious the attendings are getting their work done by reliable, dependable, consistent PA's - the attendings at your program seem to care more about that than making sure you're learning something as a resident.

Sorry you are having a rough time, but if it sucks this much in month one, why wait out another few years - start that application paperwork now and find a way to gently explain to your program director that this program is not a good fit for you.

 

[Chode]

my advice is to grow some balls

wait it out. you're what, an intern in July? Wow that's a long medical career!

Come on. Nobody lets interns in July do anything. you are a danger to yourself and others.
give it 6 months. be assertive. you really can't put PA's in their place when their place is above you and they know more than you.

Are you behaving like a whipped pup? Stand up. take some assertive training class. Learn to walk tall and kick a*s. People won't resprct you if you look at your shoes and mumble. Be a killer!

man what kind of interview did you have? Didn't you talk to the residents there and ask them how they liked the program?

what is the surgery boards pass rate?

what do the 4th and 5th years have to say? are they getting to do stuff? How do the PA's treat the upper levels? How do the nurses and OR staff treat the upper levels? what is the opinion of the program by the upper levels ( something you should have asked during your interview )

It's July and you are an intern. It's a little too early to cry because nobody let's you do anything. Doing stuff at many places is earned and not an entitlement.

You are there for scut. If I am your upper level, I'm treating you worse than the PA's. Surgical interns are slaves. Lower than amoeba. You are there to chase down labs, fix the list, manually disimpact Mrs Johnson, change dressings and take dictation ( and do my discharge summaries ).....oh yeah, and go get Taco Bell on call. IF you are a good slave, you will be taught things. The more you know, the less your upper levels have to get out of bed and do. That's the way it works

you can thank AMSA and the stupid 80 hr rule for the fact that physician extenders will be gradually making interns and the intern learning experience, obsolete. It's a bad thing for training

 

[MacGyver]

Chode,

In a program that has both PAs and residents, it is the PAs who should be doing the vast majority of scut work and the residents who should be doing the vast majority of learning new cases and procedures with patients.

Any hospital that flips those roles is not a true teaching hospital.

 

[Foxxy Cleopatra]

Originally posted by Chode

.....oh yeah, and go get Taco Bell on call. IF you are a good slave, you will be taught things. The more you know, the less your upper levels have to get out of bed and do. That's the way it works

LOL- I either must be a pretty good slave or I am working for a very cool bunch of people because I have done 3 appendectomies in the last 2 days as well as a circ. Yeah, I do my fair share of dictation summaries and deal with social issues, but no one, in any way, has made me feel like "scum."

I agree with the idea that PA's should be used to do things that are time-consuming but truly not educational, such as setting up appointments, coordinating social work/ discharge issues, etc. It would be ideal to be able to integrate them into the team to take up the time-consuming, mundane, yet important issues of patient management.

I think interns being responsible for floor patients/ taking floor call(having that amount of autonomy) is a good thing. Though the hours add up, it teaches you how to think through things- what is serious versus what can wait, and gives you familiarity with the basics.

supercut, I hope either things change at your program (perhaps since this is all new the kinks are still being worked out) or that you find another one with a better educational opportunity.

-f.c.

 

[RuralMedicine]

I initially hesitated to respond to this post as I'm not a surgery resident. However, I think this post raises several interesting issues from the role of allied health providers in teaching institutions, to the role of physicians in training physicians.

I'm a Med-Peds resident in a large university program with minimal allied health involvement. We do have NNPs in our NICUs that function at the quasi intern level--the team resident must co-sign their orders, yet we're allowed to trust them alone for most procedures (and they put in many of our PICC lines--thanks!). Using our NICU as an example for the most part the attending, fellow, resident, and interns work well with the NNPs. I think we all realized that as our training is different we do have different strengths and we can use those strengths to provide the best care as a team. (Additionally our NNPs often provide some continuity of care as the housestaff and attendings rotate in and out on a monthly basis)Procedures usually go to the residents / interns as time permits and as our system covers 2 level III NICUs and 2 level II NICUs there is more than enough to go around. Obviously if I'm attending the delivery of 26 weeker who I'll be intubating in the delivery room and then need to place a UAC and UVC I will be busy for awhile and I'm not going to be upset if the NNP replaces the PICC on the short gut infant we still haven't gotten anywhere near full feeds. Day to day and bedside intern education is the role of the resident and we (with attending backup as appropriate) supervise the interns through deliveries (one of our level III NICUs is in a tertiary care center that is the high risk OB referral hospital, the other is in our stand alone children's hospital), procedures, and guide them through difficult conversations with parents etc. Reading earlier posts in this thread makes me appreciate the system we seem to have developed. Now if we could work on that Q3 call thing!

Perhaps what I found most concerning about Supercut's post was some posters suggestion that the upper levels must have more autonomy and he (she) should put up with it for now. There is not a magical transformation that occurs when one goes from R1 to R2, R3 etc. It's just unrealistic to believe that the upper levels will be able to handle any autonomy if they haven't been allowed to take on more responsibility in escalating fashion. Ideally the interns are allowed to make decisions with guidance; as a resident the challenge is to let the interns manage their patients but foresee the potential disasters before they happen. My proud moments have not been when I've the intubation or the central line that the intern couldn't but when I've helped the intern troubleshoot through a difficult procedure and succeed. I will always remember early in my internship when I was struggling with a central line (I wasn't doing damage I just wasn't getting it ) and it was 2AM and I was expecting my resident to take over but instead he said just drop your angle a little I bet you're right there and I did and voila! Patience and perserverance are important qualities for physicians. Good attendings and residents want their interns and students to succeed.

When systems develop that don't allow interns and residents supported autonomy patient care and education both suffer. I'm currently on a MICU month at our VA hospital where I learned after a code on one of my calls that the surgery interns have no in house back up. I responded to the code, intubated the patient, and after several rounds of CPR and epinephrine for PEA we had a restoration of spontaneous circulation. At this point I realize that the poor surgery intern has no resident and is on his own with ventilator settings etc, and I'm getting paged to the MICU because the nurses think my patient in atrial fibrillation needs to be cardioverted. Obviously my focus becomes getting patients through the night so I write down ventilator settings and my pager for the intern and send him to the SICU with his patient while I return to the MICU. We and all our patients survived the night but I doubt that this was much of a learning experience for the intern, and it set up the potential for disaster as it's difficult to be in two places at once (although fortunately we had a little luck thrown into the mix and no one died).

 

[supercut]

Thank you for posting, rural medicine. What I am concerned about is that I don't think I'm getting the progressive responsibility that is necessary. Some posters responding to my concern have implied that I think I should be doing non intern level things. I don't.

The situtation I find myself in is that the PA's do everything, and make it pretty clear by their actions that they don't want me involved in pt managment. I fully realize that there are many things I won't be able to manage. However, most of the time I CAN figure out if mr so and so' s diet can be advanced, and can probably figure out how much K to give for a K of 3.2. But I very rarely get to do these things, because the PA's have such a stranglehold on the service (seemingly with the attending's blessing). Part of the problem is we have a conference every am at 7, the labs usually aren't back by then, and the PA's come in when were are in conference and get first look at the labs.

I think what bothers me the most is that the floor nurses ask the PA for any issue that comes up, big or small, whether I am there or not. I could be standing right next to the PA, and the nurse will come up, adress the PA and say, Mr x is hungry, can we advance his diet? Or show them the EKG and say, Mrs Y is in a fib. Never once has the PA attempted to turn this into an educational experience by letting me answer (or even asking me what do you want to do?)

As I said in my original post, it's a specalty service with most cases being fellow level cases. There is one other mid level resident, who spends most of the time in the OR (he doesn't get to do much) When I go to the OR, I get to do virtually nothing. Sometimes (if the RN first assistant doesn't want to) I close skin. But she has the say whether she wants to or not.

I've heard from several souces that a number of the PA have come right out and told the interns "We don't answer to you, you answer to us". I haven't been told that, but that's the vibe I get on this service.

Add to all this the fact that the attendings don't care if I'm at rounds or not. Most of the time they round when I'm off doing something, or the round during our conference, or they send the residents to conference while they stay and round with PA's. I really haven't felt like I'm part of the team. I'm just the person who comes in early to write notes so that no one else has to.

I'm about to rotate to a different service, so we will see what the PA's are like there. I'm not going to make any decisions right now. But every day, I dread going to work AND daily (and for more of the day each day) I have thoughts that I'm not getting what I need and that I want to leave.

So I'm trying to get advice because if I decide to leave I'll want to be able to act fast, espeically if I go through the match again (since there are applciation deadlines)

 

[LaCirujana]

I feel for you, supercuts. I think the posters that have been insinuating that you are trying to overstep your bounds as an intern are totally missing what you are telling us here. Your educational experience is being sacrificed for the sake of convenience and routine. What you are describing is completely inappropriate for any teaching program, community or university-based. It really sounds to me like you should start looking for a new program, even if you do have to repeat your intern year. Good luck on your new rotation. I hope it gets better.

--LC

 

[supercut]

OK, its not going much better so far. I'm about 90% decided that I need to find another program. (new service coveres ED gen surg and trauma. PA's are more tied up with complex placement issues so they let me do some floor management, but not all of it. There have been some intern level cases, none of which I have been allowed to do. The attending makes sure the students come, though. But the chief is still doing the appys on this service. I asked the attending and was informed that it was "too busy" to let an intern do an appy. I was stunned, as this service would be considered a light servce where I went to school. And next month I'll be on night float, so that will make 3 months without logging a single case.)

So the question is....how? And do I look for a PGY 2 slot for next year or go thru the match again?

If I look for a PGY 2 slot, it will have to be at a program where the interns don't have any ICU time, as I wont be getting any ICU experience here. I don't get to do any procedures here, either. So I won't be able to step into just any PGY 2 slot. I've seen the Assoc of Program Directors site (pickings seem mighty slim). How else does one learn of a PGY 2 slot? And when should I start my search?

Or would I be better off going thru the match again?

When should I approach my PD?

Any advice on how to make the switch would be appreciated!

 

[VAspa]

Supercut: Take it easy. Experiences can be rotation specific. Talk to anyone who just got out of a month of the Shock-Trauma ICU and they'll thank God Almighty for allowing July 31st to get there. See how the other rotations go.

Worrying about jumping ship right now will get you no where. That is something that will take place next year. If you want to go through the match again, well your application is already done from last year...just edit the personal statement, and that is due two-three months from now.

If you got a problem with the program, griping to us isn't going to do you any good. Take it up with the program director. They can't fix problems they don't know about. Also, state you concerns about not getting in the ICU and your program director can state his/her reasons behind the way the program is set up.

Hang in there...for now

 

[maxheadroom]

supercut,

I wouldn't get too worked up right now. Focus on doing your job and maximizing every learning opportunity. If things aren't looking up by December, you might want to get in contact with the PD/Chair at your old school (or someone else there who you know well) to advise you on your options. I know of a guy from my school who was a couple of years ahead of me. He went to a program that turned out to be a total lemon. He started talking to the PD at our school and he transfered back as a PGY-2. Didn't lose any time.

Don't burn any bridges yet, but it might be reasonable to put out some feelers to appropriate people in a couple of months. Don't tell anyone at your program what you're thinking. You don't want one of your fellow interns blabbing something at an inopportune moment.

 

[md03]

Supercut,

Wow, I feel for you. I hope things will get better for you.

Sounds like you are handling it fairly well. I don't blame you for thinking about backup plans early (though I hope you won't need them!)

As an intern myself, I can't advise you as to how to look for a PGY 2 slot or whether to go through the match again. Seems like some of the more experienced folks on the board could do that rather than berating you for posting here. This should be a safe, anynomous outlet.

Are you sure it's your program and not just being a surgery intern blues (like CP has?). Maybe you got the bad rotations early and will have good ones later? Are there PAs on every rotation?

I too, definitely have days when I hate going to work. Like on my call days, typically I get absolutely hosed with idiotic calls...pager going off nonstop, and sometimes I'm not even given enough time to respond before someone loses patience with me and page me overhead. It's enough to make me want to throw my pager out the window. But then there are days when it's not so bad, even though I'm only in the or for maybe 2 cases a week.

Good luck.