PGY-1 GS Interns, sound off!!

[UI2003]

Well we made it! One full month (almost) as full-fledged physicians! Was the experience what you thought it would be? What was the nuttiest situation you found yourself in? Did anyone actually get a day off? This is a thread created purely for fluff. Go ahead and get it off your chest - Do tell!

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[ESU_MD]

Its been a long month... Somedays I go home and feel pretty dumb, but the next day I realize I know just a little bit more.

As far as days off- yea right. I have had 2 days off total last month. 80 hrs is just a concept.

I probably could've went home early a few nights, but then I would have missed cases. I will be damned if you think I will spend all day scutting on the floor and finally get a chance to go to the OR and not be able to go to obey some 80hr work rule.

Not being on call q2 is pretty nice, but being on call is where you learn the most. and it doesnt help to be constantly made fun of by attendings and senior residents as "having it easy now"

although it seems like a good idea, 80 hrs is not going to help make better surgeons. maybe its ok for medicine or FP.

But its the rule now, so we have no choice.

 

[ArrogantSurgeon]

Originally posted by ESU_MD
I probably could've went home early a few nights, but then I would have missed cases. I will be damned if you think I will spend all day scutting on the floor and finally get a chance to go to the OR and not be able to go to obey some 80hr work rule.

although it seems like a good idea, 80 hrs is not going to help make better surgeons.

Maybe if residents didn't have to waste so much time doing worthless scut work as you say, then 80 hours per week would be more than enough time to train to actually be a surgeon. Use NPs and allied workers for all they're worth to take care of the scut so that residents can actually learn to operate and take care of patients in those 80 hours.

 

[Foxxy Cleopatra]

This will be fun!

The best part of my program is that I have been operating! I have done several inguinal and umbilical hernias, cyst excisions, a muscle biopsy, lots of circs, and 3 open appys. It reaffirmed how much I love to operate. The people have been very cool as well- hard-working but respectful; makes doing the grunt work much more bearable.

Call is service-dependent and can vary from q3 (on average) to 4 times a month. Some call is in-house, some is "home." I'm on "home call" right now but actually am at the hospital waiting for the fellow to arrive to see a patient I admitted (a minor trauma.) Thank god for the good internet connection. Yes, I *usually* have 1 day a week off (3 total since June 23rd.)

The gripes would be little things- calling to make an appointment for a patient only to get transferred or put on hold 11 times, or having to deal with social issues (patient placement, consent for kids without parental presence, etc.) Oh yeah, and sitting around, waiting for things to be done. That's probably the worst when you are tired. But all of these things are pretty minor and things I don't consider to be a problem.

I am happy here overall, I do have a life outside of work, and I feel that I am learning quite a bit.

pba? Celiac Plexus? lucas? triathelete? fourthyear? Skylizard? Others? How goes it for all of you?

 

[daredevil_2010]

I've had 5 complete (24 hours) days off so far, and I'm always forced to leave by 9:00am after post-call days. I've never had to deal with social issues such as placement. I just talk to the Social Worker or Case Manager and they take care of it. A RN does all my weekday dications and pre-op workups. A PA does most of my scut work. The secretary schedules all of the post-op appointments. Do I still have to do scut work? Of course. But at my institution things get done pretty fast here. I order a stat CXR and know I it will be done in less than 10 minutes.

I hate to hear people breaking the 80 hours work rule. That shows bad leadership in my opinion. The Chiefs and Attendings should not be allowing you to stay. It's breaking the law... and puts pressure on others to stay as well. You might say "so what?"... but almost all programs promised to be 80-hour complient.

 

[sacajaweha]

where are you training? it sounds like they have things running quite smoothly with the 80 hour requirement.

 

[Celiac Plexus]

Well,

This is my first post in a while... Internship has seriously impinged upon my "free time" activities.

After about 6 weeks I have done about 10 cases. Mostly ass cases. 'roids, pilonidal cysts, an inguinal hernia, and a BKA. I'd love to be doing AAA repairs, and whipples but hey... I'm an intern.

So far I am satisfied with ym program. I am going to keep my program anonymous at this point so that if I wish to post criticism of it, it won't get back to me. However, I have to say that so far I am pretty impressed with the way things are going.

I'm at an "old-school" type university program that is well-known. Some of the attendings are really throwback types who are maniacal control freaks. I find these guys absolutely hilarious. But that's just me. I'm sure that some of you would find them not so entertaining.

We also have some young research badasses whom I have yet to really interact with. So far I have been on the "hard" services, and I work pretty hard. The whole 80 hour thing is not really happening. I'm working probably more like 95-100 hours. However, I have a sweet call schedule that nets me 2 w/e a month.

One thing I have noticed is that 4th year of med school really spoiled me. It was tough going from basically a 4 month vacation at the end of med school to this crazy schedule. I mean, really tough. But I'm starting to adjust.

I am doing tons of floor work. It's tiring but it's pretty cool. The first day at work when the nurses were calling me "Dr." and asking what I wanted to do with my patient with a 210/98 BP, I was kinda tweaked. When I "ordered" them to give 0.1 mg clonidine I felt so strange. But even now, I am making these kind of routine decisions pretty easily.

My program is an "old-school" system where the interns really are meant to run the floor. And we do. However I have started getting more attention from attendings. I can already see how some interns are missing out on cases because they bolt from the hospital as soon as they can. I usually linger around and check all of my patients one more time after rounds just to make sure I didn't miss anything. I also sneak down tot he OR and check out late cases even after I am supposed to be gone home. I haven't scrubbed on those cases, but I have fun watching them. And I also get to talk to the chief about the plans for everyone one more time before going home. I think that our (the interns') reputations are getting established at this point and already there are some who are getting called "bangers" (a compliment) by the upper year residents, and some who get teased about "flaking" early.

I would love to be operating more, but I really feel that I am learning a great deal about patient management. I feel a little more calm every week, and those "oh ****!" moments are starting to turn in to more mellow "oh crap!" moments. Besides, the 2nd years operate like crazy, and the 3rd years operate like madmen. My chief now (5th year) has done an unbelievable amount of cases and is an amazing clinician. He is also a very cool, calm, and polite guy. I am really encouraged by the upper year residents who have operated tons, are totally at ease on the floors, have great relationships with attendings, and are generally really helpful to the interns.

Having said all of that, I am pretty beat most nights. I miss going to the occasional movie. I miss spending time with my girl. I miss the luxury of 60 minute bull sessions on the phone with my friends. I miss web surfing for porn. But so far, I feel really good about my career choice, and I feel more and more fortunate by the day to be at this program.

Now, off to my home for a few hours o' sleep!

 

[UI2003]

CP-
You have a girlfriend *and* porn? Talk about burning yer candle at both ends!

It's great to hear that most of you guys are happy with your programs. I've gotten into the OR myself a few times even though I started on a specialty service. I was surprised to get any OR time at all since I knew going in that my program was straight old skewl (as CP puts it). I tried to do the whole 'wait around at the end of the day for cases' thing but never worked out since I often only had enough time at the end of the day to catch about 3-4 hrs sleep before having to be back at work. I don't know how any program is going to make the 80 hr thing work. Most if not all of my classmates are loggin 80+ up to 120 (right around what my program averaged last year). I also heard that programs who don't comply get a $50,000 fine slapped on the PD. Has anyone heard about that?

 

[CutIt]

Someone on here already mentioned the difficulty in transitioning from a "senoritis" 4th year student to suddenly having only a few hours/day of free time. Could you all please comment on this transition, how difficult/easy it has been, and what you would have done differently to prepare for it? Also, is it making anyone rethink their surgical residency choice?

 

[UI2003]

Originally posted by CutIt
Someone on here already mentioned the difficulty in transitioning from a "senoritis" 4th year student to suddenly having only a few hours/day of free time. Could you all please comment on this transition, how difficult/easy it has been, and what you would have done differently to prepare for it? Also, is it making anyone rethink their surgical residency choice?

Well I've found it to be rotation-specific. Not every rotation will be a 4am-12am onslaught of work and cases - some actually let you out at decent hours (6pm?) in which case you can go home, eat dinner, exercise a litte AND do some reading (vesus - come home - crack open a book - fall asleep into the pages). I usually take notes throughout the day on things that I don't feel I have a solid base on and then look them up once I get home. I did the same thing in med school - the only difference now is the fact that I spend more time memorizing surgical procedures out of Operative Anatomy (Scott-Conner) as well as basic science surgery in Sabiston's. Before, I just looked up topics and printed them out using Ovid, MDConsult, and UptoDate (this worked especially well on non-surgical services I knew I'd never see again). Another good intern trick is to print out articles from above-named sources and tuck it into your pocket. If you're on a super-busy service, you can always read it during the 5-10 minutes of downtime throughout the day. I guess I've been fortunate in that the attendings at my program only pimp me on intern-appropriate things and even if I don't know - they take the time to lecture on certain topics anyway. I certainly don't feel as though I made a poor choice in specialty - on the contrary, everyday I see a few more examples that make me glad I chose surgery!

 

[girlwithaknife]

I started out on one of the harder rotations of the year, and let me tell you, the biggest impediment to the 80-hour workweek from my limited perspective is -- the federal government. I do not think it will be possible for anyone doing a rotation at a VA hospital to get even one 80-hour week. Maybe it's different at other VA hospitals, but at ours, the residents do all of the administrative work for the department, including scheduling surgeries, notifying patients after their surgery has been cancelled by some random idiot at the OR front desk, making sure all the random paperwork is complete, submitted, and not lost by someone else in order to prevent each case from getting cancelled by some random idiot at the OR front desk, etc. etc. The floors are terribly understaffed, and 75% of the nurses who are there, especially at night, are incapable of getting anything done, so that a large amount of time during morning pre-rounds is wasted unclogging NGTs, figuring out improperly recorded I/Os, talking down the raging patients who want to sue you for getting the wrong medications and the wrong meals, and handling the minor emergencies that DIDN'T get called in to the resident on call overnight, and instead have been sitting around growing into larger emergencies for several hours until you happen upon them in the morning. Not only is there no way of hiring administrative personnel to assist with the scut work that is of little to no educational value to residents, but there is also no way of firing incompetent personnel that make your life harder than it would be if they simply didn't exist. At least they have made some progress in the way of ancillary personnel - PAs, phlebotomists, etc. - but it appears the VA is caught on the ass end of the nursing shortage, and do you think VA administration is doing anything to change that?

As you can see, last month was A LITTLE frustrating. Let's hope it doesn't get worse from here...

 

[maxheadroom]

What should you do about your senioritis?? Feed it, baby. Enjoy 4th year as much as possible. My school gives tons of time off; I didn't do anything clinically after Thanksgiving. I did a dissection between interviews in January and worked with M1/M2s in April. Besides that, I spent almost a month skiing. The rest of the time was spent playing video games, playing racquetball, on trips to the beach, trips to Vegas, going out, sleeping in, and enjoying every free moment that I had. Why prepare yourself for internship?? A good friend of mine killed himself "getting ready" for intern year while I was having a good time. What was the difference? He remembered the sliding scale insulin orders better than I did. His "edge" lasted about a week and a half. After that, I was back to baseline.

No one expects an intern to know anything in July. You'll probably get a crash course in ACLS and ATLS -- that should be enough to kick start your brain. Your upper-levels will want to know about anything that you do, so don't worry too much and have fun while you can!

 

[Castro Viejo]

The amount of time my surgical internship has allowed me to hang on SDN and read is evidenced by the fact that I have no idea what has been written in this thread so far, but would like to add my contribution in support of my brothers and sisters in the scalpel business.

I love the OR. I love operating.

I've logged quite a few cases and have done some pretty interesting stuff (at least from my perspective). I just wish there was more time to read.

Good luck on your ABSITE fellow interns.

 

[droliver]

Originally posted by girlwithaknife
I started out on one of the harder rotations of the year, and let me tell you, the biggest impediment to the 80-hour workweek from my limited perspective is -- the federal government. I do not think it will be possible for anyone doing a rotation at a VA hospital to get even one 80-hour week.

You've no idea. It's been an interesting transition from 1998 when I started as an intern @ the VAMC's. The CPRS system (the windows based interface for those of you who haven't worked @ the VA) replaced the older & incomprehensible LINUX-based system which is still on the VA servers BTW. CPRS was a huge advance in simplifying lab work & the like. However, as their system has evolved they shifted all responsiblity for paperwork, orders, etc... from the clerks to the doctors which has been a huge & unproductive use of my time. The digitalized note system is great in that you don't lose charts anymore, but it takes a lot longer to do that then to scribble a quick note - I can live with this. The order entry system however is very tedious & sometimes illogical. Don't even get me started on how difficult it is to order supplies/pharmacy, enter consults appropriately, or get radiographs done right. The worst thing is that when an order or consult is not put in right, you (the provider) get no feedback on it. You may find out weeks later that some CT or endoscopy consult was refused, cancelled, or denied. Nobody calls you back out of courtesy like we tend to do when consulted.

I was doing a plastic surgery clinic last week with an attending who just took a partial VA appointment & he was amazes at how many roadblocks there are to running efficiently with the computerized note/order system. It takes the work appropriately done by lower level employees & shifts it to the most valuable & expensive resource/employee in the system (the physicians)

When I was a general surgeon, we used to see close to 75-80 patients in a VA clinic day..... this has had to be reduced by 50% almost to make things manageable with the changes

 

[maxheadroom]

Ah, the VA spa . . .

Seems to be that Physician Order Entry is coming to many hospitals, not just the VA. It's good in that there's one less middle man to screw up patient management. It does take more time. And CPRS can be annoying as hell.

My program doesn't have an associated VA. I have mixed feelings about it. The VA at my school was resident run. Attendings were around for the big cases, but all small cases were a PGY-4 or chief taking an intern through them. Great experience, but not always the best for patient care.

And that patented VA smell . . . what a horrible odor . . . nope, I guess I don't miss it!

 

[droliver]

Originally posted by maxheadroom
The VA at my school was resident run. Attendings were around for the big cases, but all small cases were a PGY-4 or chief taking an intern through them.

This traditional VA culture as a teaching hospital is very quickly changing. The feds have made a number of people examples with CRIMINAL charges for attendings not being present for cases or other duties in their contracts. In the endoscopy suite, the attendings must now be present from "scope insertion until removal". In the OR the guideline are more gray, but there are incentives fot OR workers to "whistleblow" when they feel someone is not observing the policy to THEIR satisfaction. They have also started auditing attending presence @ clinic where a clerk now comes by unannounced to document the presence or absence of the desighnated attending who's drawing their 1/8 's (eighths are how the VA pays salary... 8/8's is a full salary for example. Universities typically split eighths up among a number of attendings as an additional source of faculty salary). They have also now stipulated that there must be an electronic note on every patient on the service every day (including weekends) - you can imagine the time involved in typing notes Qday on large service seven days a week.

The new burdens of collecting VA money has made appointments there for University physicians MUCH less attractive to the point where this could become a real issue with staffing issues over time

 

[fourthyear]

I'm loving it so far, and I have only gotten to do a few cases in the OR, mostly b/c of the rotation I started on not having many intern-level cases. But I did get to do quite a few central lines, which was cool. And I still feel I'm learning from floorwork, although I'm sure it will get old soon.

My program is very serious about meeting the hours requirements, and I can honestly say I've worked 75-90/week, very close to the 80 hour average overall. This has been achieved by ensuring we all have our days and that we go home by noon post-call. The days off - I think that's the best - really, do we all have to be there for weekend rounds? No! It's so worth it to see twice the pateints when you are there in order to get a day off on another weekend. There's also a lot of cross-coverage on call, which I think is good b/c you then get more learning opportunities out of each call night b/c you deal with more patients. And again, your exchange for working extra hard on call is having more non-call nights.

It's tough on those post-call days if you want to stay for a case, but that's the way it's gotta be now - and even if you miss a cool case on your post-call day, someone else gets it and hopefully you'll get theirs on thier post-call day so it will even out eventually.

So far, I see it working out pretty well. I'd still do surgery if I had to do 120 hours a week b/c I love it enough...but I feel a bit lucky that I can have such a nice lifestyle during residency that I certainly did not count on having by choosing surgery.

 

[maxheadroom]

I forgot about the VA's crackdown. One of the ophtho's at my school was dinged a couple of years ago for billing for tons of cases. It turned out that he hadn't set foot in the building for a couple of years. I think there was a big payout on his part. Oops. For the next couple of months, the attendings were a huge pain in the ass, showing up for clinics and getting in the way all the time.

 

[The Pill Counter]

Hey dr oliver, im my previous incarnation as a hospital pharmacist, I'd spend the first two hours of every day entering med orders from the chart to the pharmacy computer, are you saying that physicians are wasting their time doing this at VA hospitals? It sounds unbelievable.

 

[maxheadroom]

Gosh, Gas Man, so kind of you to post the exact same message in two different threads. Congratulations on all the money and free time. Want to make a few payments on my studnet loans for me?

 

[Winged Scapula]

Originally posted by The Pill Counter
Hey dr oliver, im my previous incarnation as a hospital pharmacist, I'd spend the first two hours of every day entering med orders from the chart to the pharmacy computer, are you saying that physicians are wasting their time doing this at VA hospitals? It sounds unbelievable.

The tone of your message appears to imply that droliver felt that entering orders was beneath him. IMHO, this is not the droliver that has presented himself sensitively and appropriately over his tenure at SDN.

Rather, I'm sure he meant (and please correct me if I'm wrong) is that the old system (ie, handwriting orders) was much quicker, albeit perhaps more prone to mistakes due to legibility or time of orders being taken off. However, it now takes more time to enter orders, type notes, (as you often can't do them while talking with the patient as you could with a handheld chart) than it did in the old days. Administrative people are a VERY important part of the medical system; without them, hospitals would cease to run. However, the VA (and many other medical facilities) are cutting back on these positions and asking others (ie, physcians) to do what was formerly an administrative job.

I (and I'm sure droliver and others) have no problem doing paperwork - anyone that got into medicine expecting not to do any was fooling themselves. But when the paperwork comes at the expense of patient care (ie, half the patients being seen because you can't see them AND do the paperwork/order entry, in the same amount of time), I have a problem with that.

My big beef with the VA computer system, at least here locally is that the ward clerks still print out every order you type in - phenomenal waste of paper AND I couldn't believe the number of orders that would get lost - not because they weren't on the computer, but because in a long list of orders they didn't get printed or got printed and the paper stuck in someone else's chart, or not seen, or...ugh, I could go on and on.

 

[VAspa]

Long time no post for me.

I'm going to go out on a limb here gang and be specific as to which program I am writing about. I think it would be more beneficial to the 4th year medical students reading this post if everyone listed their program name when commenting about it....instead of referring to it as an "old school" program, etc.

I'm a surgical intern at the University of Texas at Houston and the administration has done everything in their power to assure the 80 hour work week is in full effect. I've had seasoned attendings make me go home after a 24 hour in-house on call period, despite my request to stay for "one more case". They've got a system in place here that had some bumps in the first week or so, but now works virtually seemlessly. On a very busy service, over the 4 week period averaged 75-80 hours per week.

It is pretty safe to say that all programs nationwide are still getting used to the new system. I'm delighted about how they've handled it at UT-Houston, and have enjoyed residency very much in the first month.

I logged roughly 45 basic operations, with 15 of them being "Surgeon Junior".

I seriously doubted the whole 80 hour thing coming into residency, and while I personally think putting surgical education on a time-clock is a grave mistake, it is beginning to win me over, and I think a solid education can be gained with the new system

 

[The Pill Counter]

Kim,
I didn't mean to imply dr oliver thought order entry was beneath him, I just hated doing it as a pharmacist, and would hate to think I'd still be doing it in a couple years time. Working with order entry systems, I can appreciate how much more time they can take compared to handwritten notes.

 

[maxheadroom]

Loved the ability to look up labs and notes by other services on any computer in the hospital. Loved that I could make a template note that automatically inserted standard labs, recent vital signs (if actually performed), current med list, and other crap into the note. Loved that I didn't have to decipher horrible handwriting. Loved that I didn't have to search the nursing station, charting area, lounge, etc for the chart to write a two line note. We had laptops on little rollers that went into patient rooms at our VA. Pretty convenient, as long as the patient didn't mind you typing during the interview.

 

[Winged Scapula]

Originally posted by VAspa
Long time no post for me.

I'm going to go out on a limb here gang and be specific as to which program I am writing about. I think it would be more beneficial to the 4th year medical students reading this post if everyone listed their program name when commenting about it....instead of referring to it as an "old school" program, etc.

While I agree that it might be helpful, I doubt that everyone or even very many would be willing to do so - its too easy to find out who people are and if one wishes to say some negative things about their program, they could be "caught", not to mention safety issues.

But if one is willing to list their program, I'm sure others would appreciate it.

 

[droliver]

Pill Counter,

order entry is not beneath me in an abstract way. What is silly is using your most expensive resource (Physician's time) to do clerical work. And no its not a value judgement, but indeed an MD's time is more valuable in an economic model for a hospital then a pharmacist (whose time is more valuable then a nurses aide, etc....)The VA system is not user friendly in this respect. As I mentioned, it cuts down by as much as half the amount of patients you can see @ busy clinics when you have to put in consults, meds, radiology request, or supplies. Some of our hand surgeons & urologists would have clinics with nearly 100 patients in a day which is now inconcievable with the extra layer of computer generated work. I love the note system, but all the other hurdles just make the whole thing incredibly frustrating. What you've done is cost shift work from the clerks to the MD's which is universally unpopular & a dubious use of limited resources.

Widespread adoption of order entry & paperless systems has been a huge failure across the nation in private practices b/c its just too inefficient a use of physician time. A number of hospitals have tried to introduce it with usually predictable results => the MD's complain until it is removed. Teaching hospitals & the VAMC have been early adopters because the resident physicians & VA surgeons have little leverage to change things. It's only HIPA compliance & the feds which are spurring the movement for many of the changes - its certainly not the Physicians

It's going to take signifigant improvements in user interface & voice recognition software to get to a point where this is widely embraced by busy physicians.

 

[Winged Scapula]

Originally posted by The Pill Counter
Kim,
I didn't mean to imply dr oliver thought order entry was beneath him, I just hated doing it as a pharmacist, and would hate to think I'd still be doing it in a couple years time. Working with order entry systems, I can appreciate how much more time they can take compared to handwritten notes.

I see - sorry if I misunderstood (looks like droliver did as well) the timbre of your message. Yes, your order entry days may not be over yet - as a matter of fact, I suspect more and more hospitals will be going to them (much to our displeasure).

 

[Sachin]

Dr. Gas.. where did you do your residency and what are you doing? General?

Sachin

 

[UI2003]

Originally posted by VAspa

I logged roughly 45 basic operations, with 15 of them being "Surgeon Junior".

Wow - someone hit the ground running! Which service did you begin with? Have you gotten any exposure to laprascopic work?

UI

 

[triathlete411]

I am now midway through my seventh week of surgical internship. For the most part I am enjoying myself. I am a little surprised by how political some things can be. I am learning which nurses to listen to.

My program is in compliance with the 80 hour work week. One week I worked 63 hours, another 100, but for the most part I am right at 80, which can still be exhausting.

Currently I am rotating at our private-affiliated hospital, which is great. My operative experience there is terrific. I have done two lap choles, assisted on an ex lap, and several breast cases. Back at home base, the operative experience was sparse. Granted, I was rotating on two non general surgery services (thoracic and urology.) My co-interns have had more time in the OR on GI, Vascular, etc.

Call is in house and averages q4. Because of the 80 hour restrictions, less residents are in-house at night, which means I am responsible for more patients on call. My last call at the big house I covered the GI, Oncology, and Urology patients. Cross-cover is extremely difficult because I only know the patient by what I get in sign-out from the intern on the service. It's overwhelming, but I have great back-up by the senior residents and am never really alone.

Overall, I am having a great experience. I haven't worked out as much as I would like, I am not eating like I should, but I am enjoying being a surgery intern, the camraderie of my fellow interns and residents, and learning to do what I have always wanted to do.