Is IM really like this?

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In that discussion, similarly, you speak as though knowledgeable when you were again very limited in experience.

It's kind of like when a kindergartner believes they know the answer to solving the national debt problem...use the money in their piggy bank. Your view is well intentioned but limited in actual substance.

This is not to be mean but to demonstrate the amount of experience you again have in this topic. You did one month of emergency medicine in one hospital likely two or three years ago. Yet, you are under the delusion you know the way in which all EPs and trauma / general surgeons relate. It's arrogant, and limited.

Thank you.
 
jesus, there's so much ego going on in this thread.
 
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GuyWhoDoesStuff said:
(but seriously, this thread is terrible)
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addon.php
 
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Wow. Another 2 pages on acronyms and a bunch of e-peen growing from absolute terminology (and looking up previous posts) from multiple people. I agree, this thread is terrible.
 
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HopefulReapp said:
Is all of IM like this? Is it any more exciting as a med student or physician? I've shadowed specialists in out patient settings and enjoyed it much more (more alert/healthier patients.) Does this mean that I shouldn't consider IM in the future?
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IM rotation convinced me never to do it again. Choose something where you can actually do some good. Plus, the IM mentality is just absurd - constant repetitive blood drawing, finding incidentalomas and random abnormal lab results, massive workups instead of trying to focus on what is most likely, and no ability to sign anything out to the night team unless everyone is "stable." If they were "stable" they wouldn't be in the hospital. Read Samuel Shem's "The House of God" for a full explanation.
 
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Attending101 said:
IM rotation convinced me never to do it again. Choose something where you can actually do some good. Plus, the IM mentality is just absurd - constant repetitive blood drawing, finding incidentalomas and random abnormal lab results, massive workups instead of trying to focus on what is most likely, and no ability to sign anything out to the night team unless everyone is "stable." If they were "stable" they wouldn't be in the hospital. Read Samuel Shem's "The House of God" for a full explanation.
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House of God is the pinnacle of why IM sucks. The only difference is now there are work-hour limits. As "important" as IM thinks it is, you wouldn't know it bc it gets crapped on by every other specialty in the hospital. Even hospitalists only like their job due to the time off and it pays well.
 
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Attending101 said:
and no ability to sign anything out to the night team unless everyone is "stable."
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The medicine night float at my hospital is insane. As a surgery resident I shake my head at it. No respect for duty hours or each others time.
(a) the medicine residents all routinely stay 1-2 hours past the designated sign out time, because the mentality is that it's not okay to sign out until 100% of your daily work is done. So even if it's just someone sitting there finishing the last progress note, they aren't allowed to sign out. So of course the pager goes off and then they have even more tasks to take care of.
(b) The night team doesn't check on any of the existing patients they are covering unless explicitly told to follow up on something or a patient crashes (ICU/code level crash). They're too overworked with the admissions they are responsible for to do so, and are routinely covering something like 75 patients at a time.
(c) Along with (b) - they put in crazy orders to "protect the night float" - routinely ordering prn benzos, ambien, antipsychotics on patients without even thinking about it "in case" they need it overnight so that the nurses don't page to ask for it
(d) On some of the services, due to the staffing structure, patients can go >20 hours without being seen by an attending or having the case staffed with an attending.
 
southernIM said:
The medicine night float at my hospital is insane. As a surgery resident I shake my head at it. No respect for duty hours or each others time.
(a) the medicine residents all routinely stay 1-2 hours past the designated sign out time, because the mentality is that it's not okay to sign out until 100% of your daily work is done. So even if it's just someone sitting there finishing the last progress note, they aren't allowed to sign out. So of course the pager goes off and then they have even more tasks to take care of.
(b) The night team doesn't check on any of the existing patients they are covering unless explicitly told to follow up on something or a patient crashes (ICU/code level crash). They're too overworked with the admissions they are responsible for to do so, and are routinely covering something like 75 patients at a time.
(c) Along with (b) - they put in crazy orders to "protect the night float" - routinely ordering prn benzos, ambien, antipsychotics on patients without even thinking about it "in case" they need it overnight so that the nurses don't page to ask for it
(d) On some of the services, due to the staffing structure, patients can go >20 hours without being seen by an attending or having the case staffed with an attending.
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Yup, that sounds about right. Don't see what is wrong with c), if there are no contraindications or b) if there is no issue.. IM doesn't have the luxury of turfing their patients to others and say their problem isn't a "medicine" problem (the way surgery can say their problem is not a "surgery" problem). Heck even on the patients where IM feels it is surgical in nature, Gen Surgery has the ability to see the patient, evaluate, and just say, they'll continue seeing the patient as a consult, without actually taking the patient.
 
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DermViser said:
Yup, that sounds about right. Don't see what is wrong with c), if there are no contraindications or b) if there is no issue.. IM doesn't have the luxury of turfing their patients to others and say their problem isn't a "medicine" problem (the way surgery can say their problem is not a "surgery" problem). Heck even on the patients where IM feels it is surgical in nature, Gen Surgery has the ability to see the patient, evaluate, and just say, they'll continue seeing the patient as a consult, without actually taking the patient.
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A lot of it is just cultural.

We pretty much never have standing prn orders for something like ambien or haldol - unless it is a patient who has been taking it in the hospital for several days and has tolerated it each time. In general our program would expect that if such a medication is needed the MD should probably know about it. And as faytlnd posted in the surgery forum - I don't generally prescribe meds like benzos or ambient for inpatients for things like "sleep" when they haven't been taking it before. If you look at the average medicine service in our hospital, 3/4 the service will have standing prns for those types of meds even though they've never taken it before in their life and haven't requested it as an inpatient.

And we expect that our interns will lay eyes on pretty much all the inpatients at least a couple times over the course of the night (and it's mandated that they perform and document a post-op check on all fresh post-op patients), and we expect that they'll be keeping close eyes on their Q4 hr (or more often in the ICU) vitals and I/Os. In contrast, the medicine teams won't typically even look at those things (much less the patient) unless they get paged by the RN that there is a problem. But - the medicine teams are responsible for all their existing patients and a ton of new admits overnight. Our intern's sole job is to take care of the existing inpatients (new admits/consults/operations get handled by a completely separate team of more senior residents) so of course they have time to keep a closer eye on them.

The attending staffing thing is my own quixotic crusade. I've seen a lot of medicine patients get pretty under or mis managed overnight. By the time an attending sees them and tries to course correct the plan of care they've often been there for an entire day. It's just not an appropriate level of oversight for trainees - especially when it's early in the year and the "senior" resident has about 6-7 months of inpatient medicine under their belt.
 
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Anastomoses said:
Say you want to do vascular or trauma surgery for about 10 years and then you wanna chill...would you just have to redo a residency in the chill specialty? That would suck. Or would you just cut down on your surgical hours?
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It's exceptionally unlikely that after 10 years of practicing surgery you'd be able to go back into a residency in a different field. Not 0% chance, but very very unlikely. Plus in order to get into whatever "chill" field you're seeking you'd have to redo a residency for 3-4 years which is decidedly non-chill.

In vascular surgery there are ways to carve out a more lifestyle friendly practice - do primarily veins which involves a lot of office procedures and outpatient cases and fairly low morbidity (at least when compared to the rest of vascular). Or, do what one guy I know did and get yourself plugged in as the main access referral guy for a huge network of dialysis clinic.

In trauma - you could try to find a practice or employer who would reduce your call frequency; but everything is a trade-off and that comes with less $$. Or you could try and build up an elective general surgery practice with mostly outpatient cases like hernias - but that can be tough as you'll rely on PCPs to refer cases to you and they won't have much incentive to just send you the easy outpatient stuff if you won't take care of the other stuff they send you.
 
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Anastomoses said:
You're scaring me. I'm beginning to worry that there isn't anything I'm going to like.

Say you want to do vascular or trauma surgery for about 10 years and then you wanna chill...would you just have to redo a residency in the chill specialty? That would suck. Or would you just cut down on your surgical hours?
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The number of former trauma surgeons now just doing breast surgery is not insignificant. Its a good way to have a more "chill" lifestyle.
 
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Anastomoses said:
You're scaring me. I'm beginning to worry that there isn't anything I'm going to like.

Say you want to do vascular or trauma surgery for about 10 years and then you wanna chill...would you just have to redo a residency in the chill specialty? That would suck. Or would you just cut down on your surgical hours?
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If you're going into surgery with the intention to chill, surgery may not be the best of pathways and will be a very rough road for you.
 
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DermViser said:
If you're going into surgery with the intention to chill, surgery may not be the best of pathways and will be a very rough road for you.
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The very problem is I don't want to chill but I don't want to be short-sighted and believe that I will never ever want to chill down the road. I have to keep in mind the me of 15 years from now.
 
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DermViser said:
If you're going into surgery with the intention to chill, surgery may not be the best of pathways and will be a very rough road for you.
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I don't think this is necessarily true. The attending lifestyle, depending on the field of surgery you go into, can be pretty decent hours. Gen surg attendings worked 7 to 5 at my hospital, and there was an acute surgery team to cover night emergencies. They'd have to do call like one weekend a month, and this was all in academics.

Sure, surgery residency (and fellowship) is absolute hell, but it's similar to neurosurg. If you do a spine fellowship after a neurosurg residency, your attending lifestyle can be pretty chill (at least compared to doing 2AM craniotomies every saturday night)
 
evilbooyaa said:
I don't think this is necessarily true. The attending lifestyle, depending on the field of surgery you go into, can be pretty decent hours. Gen surg attendings worked 7 to 5 at my hospital, and there was an acute surgery team to cover night emergencies. They'd have to do call like one weekend a month, and this was all in academics.

Sure, surgery residency (and fellowship) is absolute hell, but it's similar to neurosurg. If you do a spine fellowship after a neurosurg residency, your attending lifestyle can be pretty chill (at least compared to doing 2AM craniotomies every saturday night)
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Those are practice specfic, not specialty specific, and yes the residency is utter hell.
 
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DermViser said:
Yup, that sounds about right. Don't see what is wrong with c), if there are no contraindications or b) if there is no issue.. IM doesn't have the luxury of turfing their patients to others and say their problem isn't a "medicine" problem (the way surgery can say their problem is not a "surgery" problem). Heck even on the patients where IM feels it is surgical in nature, Gen Surgery has the ability to see the patient, evaluate, and just say, they'll continue seeing the patient as a consult, without actually taking the patient.
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I think this why they need to incorporate more non-teaching floors for patients with minor/babysitting/social etc issues so the IM residents can be more efficient.
 
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jumpmanv15 said:
I think this why they need to incorporate more non-teaching floors for patients with minor/babysitting/social etc issues so the IM residents can be more efficient.
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Most hospital do this... they have a hospitalist service where easy admissions and social issues go to fester.
 
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Anastomoses said:
The very problem is I don't want to chill but I don't want to be short-sighted and believe that I will never ever want to chill down the road. I have to keep in mind the me of 15 years from now.
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I'm the opposite, I only want to chill :)
 
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HopefulReapp said:
Incoming ms1 here. I've been working full time as a patient aid on a med surg floor and it has certainly been rewarding and a great learning experience, but it has also shown me a lot of negative aspects of medicine. I don't see much improvement in my patients from day to day. The majority of illnesses are suicidal ideations, uncontrolled diabetes, dementia, hypertension, etc. Many of them refuse to help themselves, are frequent patients, or are waiting months to be placed.

I'm just wondering if my perspective is incredibly skewed by being an aid as opposed to the physician. I get kicked, screamed at, pooped and peed on, and a bunch of other things daily.

Is all of IM like this? Is it any more exciting as a med student or physician? I've shadowed specialists in out patient settings and enjoyed it much more (more alert/healthier patients.) Does this mean that I shouldn't consider IM in the future?

Thanks everyone


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Wow very very cool I was a Nurse's Aid on a Med Surg Unit as well, I had very similar thoughts to yours. Almost the exact same, kind of creepy. Med Surge is one hell of a ride from the Nurse's and Aide's point of view.

Anyway, although IM is mainly the management of chronic disease, you have to take into account you do have an impact in their care as a Doc that you didn't have as an aide. You may not be "curing" many people, but you can manage them the best you can and develope relationships w/ the patients that are important
 
AnonymousD.O. said:
Wow very very cool I was a Nurse's Aid on a Med Surg Unit as well, I had very similar thoughts to yours. Almost the exact same, kind of creepy. Med Surge is one hell of a ride from the Nurse's and Aide's point of view.

Anyway, although IM is mainly the management of chronic disease, you have to take into account you do have an impact in their care as a Doc that you didn't have as an aide. You may not be "curing" many people, but you can manage them the best you can and develope relationships w/ the patients that are important
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The development of relationships usually occurs in outpatient IM, not inpatient IM. That being said, IM residency is nearly all inpatient.
 
DermViser said:
The development of relationships usually occurs in outpatient IM, not inpatient IM. That being said, IM residency is nearly all inpatient.
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Good point, I can see where over the years it would be draining to be seeing patients in the hospital who have short stays. I am naive to what it is really like (MS1), but I hope that if I do go IM, which I am considering strongly, that I can stay enthusiastic and even if patients are present for a short time, have an impact in some way.

I'm sure there are other people like me out there, that ended up getting burnt out with IM. I guess in rotations I'll get a better feel for what it is really like
 
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only thing that sucks about IM is pay, tbh, i could name a dozen specialties that suck more, practice wise.
 
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Kahreek said:
only thing that sucks about IM is pay, tbh, i could name a dozen specialties that suck more, practice wise.
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IM could pay me $500,000 and I still wouldn't do it. Trust me, it's definitely not the money, why IM has such low physician satisfaction.
 
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big money few hours- high satisfaction
big money big hours - surgery
few money big hours - im
 
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Kahreek said:
big money few hours- high satisfaction
big money big hours - surgery
few money big hours - im
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Uh, no. Have you SEEN the medical problems that a Hospitalist (who has big money and controlled hours) is exposed to and has to take care of?
 
i've seen some of those problems, yes. Although it must be worse to feel them on your own skin. But i guess every profession has downsides. And i understand IM can be screwed more often based on how the system is built.
 
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DermViser said:
Uh, no. Have you SEEN the medical problems that a Hospitalist (who has big money and controlled hours) is exposed to and has to take care of?
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Hospitalists dont make big money.
 
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southernIM said:
The medicine night float at my hospital is insane. As a surgery resident I shake my head at it. No respect for duty hours or each others time.
(a) the medicine residents all routinely stay 1-2 hours past the designated sign out time, because the mentality is that it's not okay to sign out until 100% of your daily work is done. So even if it's just someone sitting there finishing the last progress note, they aren't allowed to sign out. So of course the pager goes off and then they have even more tasks to take care of.
(b) The night team doesn't check on any of the existing patients they are covering unless explicitly told to follow up on something or a patient crashes (ICU/code level crash). They're too overworked with the admissions they are responsible for to do so, and are routinely covering something like 75 patients at a time.
(c) Along with (b) - they put in crazy orders to "protect the night float" - routinely ordering prn benzos, ambien, antipsychotics on patients without even thinking about it "in case" they need it overnight so that the nurses don't page to ask for it
(d) On some of the services, due to the staffing structure, patients can go >20 hours without being seen by an attending or having the case staffed with an attending.
Click to expand...

About b, usually for night coverage, once they are signed out, I wouldn't imagine people would physically round on all of them, or computer round, unless there is something specific noted to check at XXX time. A lot of night residents say they haven't laid eyes on any of the patient they have been checked out overnight. I thought it was universal that for night coverage, people check on those patients only if they need to monitor them specifically for something, or if called. 90% of the time, usually there is nothing to do which makes sense. Of course, if a bunch of people crash, well then that's a different story :p

Which makes call from home turn into not so bad to "Crap, might as well sleep here since I need to closely monitor this person!"

And don't attendings usually see the patient once in a 24 hour setting? Or in your shop, do they visit the resident patients more? The attendings have staffed my patients once a day :/
 
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KnuxNole said:
And don't attendings usually see the patient once in a 24 hour setting? Or in your shop, do they visit the resident patients more? The attendings have staffed my patients once a day :/
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Attendings at least discuss, if not see, any new patient before they get admitted to a surgical service. If I admitted a patient and carried out a plan without talking to an attending first, and they found out about it for the first time the following morning...I'd get fired.

Yes, for existing inpatients they likely see them only once a day - the key difference to me is that the attendings drive the plan on any new admit from the very beginning. On a medicine service it will often be nearly an entire day before they see or hear about new patients (i.e. patient gets admitted at 2pm - intern/resident forms plan, signs out to night float, who signs back in to day team, who then staff with attending the following morning at 9-10 am during rounds).

We've had multiple times where one of our attendings who has seen and examined a patient calls the medicine attending to discuss a plan for operative intervention...and the medicine attending has never heard of the patient.

KnuxNole said:
About b, usually for night coverage, once they are signed out, I wouldn't imagine people would physically round on all of them, or computer round, unless there is something specific noted to check at XXX time. A lot of night residents say they haven't laid eyes on any of the patient they have been checked out overnight. I thought it was universal that for night coverage, people check on those patients only if they need to monitor them specifically for something, or if called. 90% of the time, usually there is nothing to do which makes sense. Of course, if a bunch of people crash, well then that's a different story :p
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Like I said...it's cultural/program differences. As I said before, it's an expectation that our interns are physically checking on just about every patient (except someone who is rock stable that they have been seeing for days), and computer rounding on them Q4 hrs (or whatever the vital frequency happens to be). For a fresh postop it's definitely expected that they see the patient and document it with a postop check.

Which makes call from home turn from not so bad to "Crap, might as well sleep here since I need to closely monitor this person!"
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Which is why home call has been such a loophole for abuse in surgical programs.
 
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southernIM said:
Yes, for existing inpatients they likely see them only once a day - the key difference to me is that the attendings drive the plan on any new admit from the very beginning. On a medicine service it will often be nearly an entire day before they see or hear about new patients (i.e. patient gets admitted at 2pm - intern/resident forms plan, signs out to night float, who signs back in to day team, who then staff with attending the following morning at 9-10 am during rounds).

We've had multiple times where one of our attendings who has seen and examined a patient calls the medicine attending to discuss a plan for operative intervention...and the medicine attending has never heard of the patient.
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That's all a bit worrisome.

When I was an intern, if I was admitting during the day I'd touch base with my attending (we admitted for our own team, but no cross-admits to other teams) after examining them in the ED and formulating my plan. This was usually a phone call from the work room in the ED to wherever my attending was (rounding, doing other work). By this point I may or may not already have put in some skeleton admit orders, but I'd hash out the plan with my attending before anything else was final. Often times if he wasn't particularly busy, he'd come down and quickly lay eyes on the patient too.

If I was admitting overnight, I'd run my plan by my senior resident. It was not standard practice for me to discuss the patient with the overnight hospitalist unless I absolutely felt the need to. Then signout from me to the daytime medicine resident(s) as usual in the morning, and they'd round with the attending.

Technically, any patient admitted before midnight (so, between 7pm when I began night float until 12 midnight) was supposed to be seen and rounded on with me and the night time hospitalist, but this was on contingent on us having the time to do so.
 
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southernIM said:
I agree it's a bit worrisome. The medicine residents call it autonomy.
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I mean, a certain degree of autonomy is helpful, but it needs to be in a graduated manner. It's difficult to balance autonomy and safety.
 
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