Trouble with fellowship

[Levofriend]

I’m a pulmonary/critical care fellow, and I’m finding myself surprised with hospitalist requests and interactions lately. I find that I’m frequently tasked with: obtaining IV access, requests for educational materials for the residents on their team, consults for procedures that are not pulmonary related (Like lumbar punctures), insistence on performing procedures that I don’t think are appropriate, etc. I use the word request but it feels like the expectation is that I do whatever they say. I feel more like their trainee than colleague. This is totally opposite of the vibe/feel I get when working with my actual attending. Maybe since I was a hospitalist prior to fellowship, I’m having trouble adjusting to this. I guess the easiest thing to do is to avoid conflict by accepting it. Im wondering if anyone else has had this experience before and how they dealt with it.

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[rokshana]

I’m a pulmonary/critical care fellow, and I’m finding myself surprised with hospitalist requests and interactions lately. I find that I’m frequently tasked with: obtaining IV access, requests for educational materials for the residents on their team, consults for procedures that are not pulmonary related (Like lumbar punctures), insistence on performing procedures that I don’t think are appropriate, etc. I use the word request but it feels like the expectation is that I do whatever they say. I feel more like their trainee than colleague. This is totally opposite of the vibe/feel I get when working with my actual attending. Maybe since I was a hospitalist prior to fellowship, I’m having trouble adjusting to this. I guess the easiest thing to do is to avoid conflict by accepting it. Im wondering if anyone else has had this experience before and how they dealt with it.

Didn’t you say you are a fellow?
you are a trainee… your attending is their colleague.

and it’s always important to avoid conflict with an attending… talk to your attending or PD to see if it’s appropriate and let th deal with it.

 

[Levofriend]

Didn’t you say you are a fellow?
you are a trainee… your attending is their colleague.

and it’s always important to avoid conflict with an attending… talk to your attending or PD to see if it’s appropriate and let th deal with it.I

Didn’t you say you are a fellow?
you are a trainee… your attending is their colleague.

and it’s always important to avoid conflict with an attending… talk to your attending or PD to see if it’s appropriate and let th deal with it.

I’m a board certified internist myself with my own license. I have the same credentials that they do.

 

[rokshana]

That may be, but in the hierarchy, you are a trainee and they are attendings…it can be hard going back to training after working for a few years… I went back to fellowship after 2 years as a hospitalist so it wasn’t that long…but I also did medicine as a second career and pretty much all my senior residents were much younger than me, so learned to make the adjustment earlier in training.

if you don’t learn to accept the hierarchy, you will be in for a rough 3 years…just saying…you very well be at the same level in your mind…but you are a trainee in theirs…especially if you were not attending hospitalist at that hospital.

 

[Bobblehead]

I’m a pulmonary/critical care fellow, and I’m finding myself surprised with hospitalist requests and interactions lately. I find that I’m frequently tasked with: obtaining IV access, requests for educational materials for the residents on their team, consults for procedures that are not pulmonary related (Like lumbar punctures), insistence on performing procedures that I don’t think are appropriate, etc. I use the word request but it feels like the expectation is that I do whatever they say. I feel more like their trainee than colleague. This is totally opposite of the vibe/feel I get when working with my actual attending. Maybe since I was a hospitalist prior to fellowship, I’m having trouble adjusting to this. I guess the easiest thing to do is to avoid conflict by accepting it. Im wondering if anyone else has had this experience before and how they dealt with it.

obtaining IV access: Check with your service attending whether this is something your consult service does. If it's in the ICU then yes, it's your job. If it's for a floor patient whom you haven't even consulted on this may be something that needs to be discussed with your fellowship director on a global basis because it may not be an appropriate use of your time. If it's an IV for the CTPA on a patient you were just consulted on for r/o PE you should probably attempt to help if the primary service isn't doing their job.

requests for educational materials for the residents on their team: Teaching is part of your responsibilities in a teaching hospital. If you're busy with other clinical work you may need to prioritize this for later in the day or the following day, otherwise it will be beneficial to build up a folder of generic teaching materials on asthma, COPD, basic ILD. This does not have to be as in-depth if it's targeted towards a general audience.

lumbar punctures: Again, check with the pulmonary service attending whether this is something your section provides as a service to the hospital or by tradition or whatever. You may also wish to inquire whether they would like to be present for the critical portions of the procedure so you may bill for it which might change their outlook on whether this is an indicated procedure

 

[NotAProgDirector]

None of these things would be considered acceptable where I am. This is a culture issue -- find out what the culture is there, and what's considered appropriate.

 

[Raryn]

Two parts to this discussion:

1) You are a trainee and are not the hospitalists colleague. Yes, you have the same (if not more) training than they do - but they are credentialed to work independently in their current context and you are not. Similarly, the PGY8 neurosurgery resident is a trainee who is "outranked" by the brand new IM attending who might only be 4 years out from medical school. Is that fair? Not necessarily. But that's how it works.

If you disagree with the hospitalists management, you're allowed to say so - anyone is allowed to say so - but if they insist, your recourse is not to keep arguing. Your recourse is to call your own attending and inform them - and let the attendings sort it out.

2) While you *are* a trainee, you're not their scut-monkey. It may be appropriate to request you to do certain procedures - but peripheral IV access and lumbar punctures are almost certainly not appropriate. You should bring it up with your own attendings and program leadership and see what the policies are regarding what you are and are not responsible for.

 

[Levofriend]

None of these things would be considered acceptable where I am. This is a culture issue -- find out what the culture is there, and what's considered appropriate.

I never thought of this before, but I think you’re right. I went to a different place for residency and we would have never done any of the above to the fellows. Maybe I’m having trouble adjusting to the new role and learning the culture. Thanks everyone. Good point to ask the attending what is and is not appropriate

 

[The kitchen sink]

I’m a pulmonary/critical care fellow, and I’m finding myself surprised with hospitalist requests and interactions lately. I find that I’m frequently tasked with: obtaining IV access, requests for educational materials for the residents on their team, consults for procedures that are not pulmonary related (Like lumbar punctures), insistence on performing procedures that I don’t think are appropriate, etc. I use the word request but it feels like the expectation is that I do whatever they say. I feel more like their trainee than colleague. This is totally opposite of the vibe/feel I get when working with my actual attending. Maybe since I was a hospitalist prior to fellowship, I’m having trouble adjusting to this. I guess the easiest thing to do is to avoid conflict by accepting it. Im wondering if anyone else has had this experience before and how they dealt with it.

We had this come up multiple times when I trained in fellowship, worked at a 'fellow' run hospital, and every service was extremely silo'd to say the least. The hospitalist service and IM residents hardly 'touched' the patients, if you know what I mean. Some of the IM residents wanted to learn, however, sometimes running a busy ICU, its not feasible for me to leave and supervise that procedure.

From day 1 of our fellowship, our PD made it clear that we were not an IV or procedure scut service, and so we literally would just say no and end the conversation right there. Now if the patient truly required a Critical care consult for higher level of care and the requested procedure, I would transfer the pt up to the ICU and perform it there in a more 'controlled' environment.

Often times in the hospital, on the general medical wards, the intensivist may be the only person equipped to perform routine procedures (PIVs, LP, para, thora, art line, CVC etc), as the IM procedural requirements are basically non-existent and nowadays more and more hospitalist opt to sign on for non-procedural services and so that leaves you as the most qualified proceduralist.... and Crit care is utilized as a safety net in a lot of hospital systems

TL;DR - you can say no, as long as you're service/PD support you, that's what we did at my hospital and they found ways to get the patients the procedures they needed (IR ended up doing most of those procedures)

edit: also felt it was a shock to me as well going into fellowship, as I trained at a 'resident' run hospital, so all of those 'routine' procedures I mentioned were done by residents.... PGY 3 would supervise PGY 2's while PGY1's observed, then you moved up in PGY and the cycle of procedural training continued, it worked quite help actually

hope that helps

 

[AlbinoHawk DO]

You need to set boundaries early on and the only way would be through talking to your attending. You shouldn't be treated as a procedures team or expected to teach residents outside of the service

 

[BicepsTriceps]

I’m a pulmonary/critical care fellow, and I’m finding myself surprised with hospitalist requests and interactions lately. I find that I’m frequently tasked with: obtaining IV access, requests for educational materials for the residents on their team, consults for procedures that are not pulmonary related (Like lumbar punctures), insistence on performing procedures that I don’t think are appropriate, etc. I use the word request but it feels like the expectation is that I do whatever they say. I feel more like their trainee than colleague. This is totally opposite of the vibe/feel I get when working with my actual attending. Maybe since I was a hospitalist prior to fellowship, I’m having trouble adjusting to this. I guess the easiest thing to do is to avoid conflict by accepting it. Im wondering if anyone else has had this experience before and how they dealt with it.

As a current hospitalist on J1 waiver job applying to PCC in 2-3 years your post made me a bit anxious lol

But as everyone stated above. Just ask your PCC attending if this is something you should be doing or not. Because he or she will end up co-signing your procedure note and billing for it.

You are a trainee meaning you're almost absolved of any liability and your attending will take full responsibility so enjoy that before you're a PCC attending and fully responsible again.

The hospitalist asks you to do something.
Your replay: Sure but let me run this by my attending first to see if (s)he's okay with it and I'll let you know

 

[killerleaf]

I know that recently, our Pulm/CC fellows have been asked to take on some "out of the box" duties, as it has been "all hands on deck" due to COVID surges. Is this also a possibility?

 

[rokshana]

All hands on deck

Aka abusing and exploiting physicians in training for free services beyond the gaggle of free services we do daily

All under the guise of “patient care” so that the hospital can save/ make money

I like it. It’s an incredible plan which works every time!

Wow! When did they stop paying residents and fellows??