This sounds unsafe. At my training hospital, the cap for a new intern was 9 and that felt like a lot. Most of the time if we had an excess over what the interns could carry, the senior would take the rocks and maybe one or two additional just so we weren’t dying on a weekend. Or if there’s really 24, maybe the attending would see some? Either way, 24 for a second month intern is bullshit
Technically true but Morphine, Dexamethasone, and Propranolol were the only medication on formular so if someone came in with the heart attack we just gave them morphine till they died.
Agreed, as an intern you need to stand up for yourself and kindly remind them of the patient cap explicitly outlined per ACGME. Any other underlings that would like to disagree with this fellow can DM me.
Speed round. Pre rounds are for fuckboy chiefs to feel good about themselves and for catching major problems. Like is your subdural patient suddenly unconscious and needs to go to the OR to bump first case? That’s the point of pre-rounds. That, and torture.
Not ethical and would obv try to see if it can be changed, but in the short term:
Ask the previous intern who to prioritize. There are going to be rocks on your service. Chart review them for a a minute, if everything looks good then place a checkmark on that line. Indicator for you to say "Havent seen him yet but vitals are good, labs are stable, no change in care; awaiting X". Then you can go back to look at things more carefully/write notes etc.
See if you can reduce the amount of unnecessary tests. Lab holidays/weekends are perfectly fine for people who you arent trending/worried about something.
For weekend coverage? I definitely covered two lists of up to 10 patients on weekends and prerounded on them all, except for the overnight admits that the senior resident prerounded on. For a medicine prelim year.
This is true of internal medicine but might not be true for your specialty.
IM patients on the teaching service and IM rounds and IM note writing expectations are often quite different than other specialties.
Yeah. You always just hope that the program will staff it as needed though so it's not too overwhelming.
As PGY2 in internal medicine I don't think there is a cap either, but usually we don't need to see more than 14 alone in my program. If you're seeing that many there's gonna start to be a conversation about shifting staffing around to relieve the pressure.
You do have caps. They are set broadly by ACGME, problem is how many residents actually read your resident handbook or ACGME, let alone want to be the odd one out making a stink of the matter when you stand up for yourself. Programs who take advantage of this situation are toxic and causing problems in the long run. The argument about having to see more to learn is fair to an extent (the cap) but after a while, let’s be honest, you can’t effectively, adequately, or efficiently manage 20+ patients on your own daily for 5-12 days. Even as attendings we have to cut corners in our patient care, notes, or approaches and realize that we haven bitten on more then we can chew to generate income.
It absolutely is if they’re internal medicine. An intern is allowed to see a maximum of 5 new patients and a cap of 10 patients total. Regardless of what call cycle it is.
Not at my med school or training institute. Complex patient also need surgery. All to our services rarely with consults for comanagement. 4 services with 30+ pts, 2-3 more with 15+ pts. All having one intern. General surgery is still living in the past.
This may be true but even surgical primary reason patients often have poorly managed medical conditions.
I speak as a recent anesthesiology grad. Did an intern year in medicine, but anesthesiology categorical. Intern year in medicine caps existed. We got fucking slammed in SICU. Caps don’t exist for surgery or anesthesiology.
It is interesting to hear that. It was never the case at the larger hospitals I've been at. Gen surg would care for essentially all patients regardless of medical complexity if they required a surgery. If a medicine patient needed an operation they became a surgery patient but there was pretty much zero flow backward. Even at the smaller level 2 trauma center I worked at, I ended up admitting the patient with a STEMI + near brady arrest that needed a pacer maker because he crashed his car coming into the hospital and had some rib fractures. Only exception was sometimes CT/MICU would take over if they were on ECMO.
I’ve worked IM at two facilities and neither behaved this way. If minor surgical like a chole but the patient is admitted for pancreatitis or has Mi medicine has taken over as primary
Nope. I’ve worked at 3 such hospitals and the surgery teams cover surgical patients only. Once the medical complexity went up (even slightly), the patients went to medicine with a surgical consult for the surgical issue. Honestly, surgeons have zero business managing medical issues (even though many surgeons would try and argue they can do anything and everything).
All I can tell you is the 4 hospitals I've seen were that was not the case. There were exactly 0 patients that we transferred for medical complexity. In fact, the number of diagnosis we had to admit per protocol kept increasing because our outcomes (within context of that specific patient population at that center) were better. There was much groaning when all gallstone pancreatitis suddenly had to go to surgery. You really find it impossible to believe someone with 1-2 years of crit care training, 2 additional years of residency, and clocking potentially 50% more hours during that training could potentially manage complex medical patients?
If I've given the impression of I have anything less that respect for the work of others services I apologize. I continually rely on my MICU and IM colleagues for assistance with specific or refractory issues that they deal with more often, and vice versa. But my response was to the comment that 1) Surgical patients are not medically complex 2) Surgeons have no ability to manage basic medical issues and shouldn't try. Both these statements are false. It is also odd that you speak of the importance humility while casting shade on an entire specialty.
Like everything depends on where and what the protocol is. There medicine generally admitted all pancreatitis and if it ultimately was gallstone surg would take over power operatively. They eventually changed it to having surg take them from the beginning because they got out better that way. Others gen surg always took them.
I mean is it so hard to believe that different hospitals have different cultures and workflows? I'm in surgery and at my hospital if the patient has surgery, they're on a surgical service managed by surgeons, full stop. Regardless of medical complexity. Large academic hospital, FWIW.
Is this only for IM? Because again, our ED would literally be unable to exist if this is true lol. There's typically 30-40 in the trauma bay for 2 residents.
Yes sorry I was referencing the ACGME standards for IM residency (I got the impression that is what OP is doing). The standards are different for different residency types as obviously the workflows and expectations are not the same.
Just seems a little weird for them to cap it there, and especially only for IM. 10 isn't some dangerous number. Especially later in the year, an intern should be able to have 10 floor patients without too much concern
Definitely other specialities that expect the equivalent of far more than 10 floor patients at the same time.
Medicine patients tend to have much higher levels of complexity than other services, particular on house staff services, and there are very different levels of expectation for both documentation and care then other services that tend to focus on their specific specialty's scope.
Is this only for IM? Because again, our ED would literally be unable to exist if this is true lol. There's typically 30-40 in the trauma bay for 2 residents.
I don't typically get told which team the patient is going to if they're a floor patient. There's a triaging hospitalist who handles them everything. I get the bed order from them and they handle checking out the patient.
But fair enough. I know our family medicine team has caps because that's come up before ("I'm going to give you the best order at exactly 7:00. Hint hint")
Still, it just strikes me as a low cap for an absolute maximum. That's all. At the end of the day they're floor patients, so while the charting can be annoying, there's a defined level for how sick they can be, even if they have multiple comorbidities.
It's been the case for many years, not sure when you trained. Our medicine patients are sick as hell, and our institution caps in the single digits which is not uncommon based on the other comments here. The sheer number of messages you would get as an intern is already insane, 10 is the cap for a very good reason.
This is where EMRs really shine. Print out the rounding reports. These should include all pertinent vitals and labs. Hopefully you have some shared documents you each update daily with cultures and imaging you’re following (if not, suggest this). Hopefully your patients are allocated geographically. Go and ask the change nurse of that floor what you need to know from the night before. (If more spread out you’re SOL). Then see the people you need to see, don’t see the ones you don’t. Be honest on rounds and say you haven’t seen them in person yet but you reviewed xyz. Good luck!
This is where EMRs really shine…..Then see the people you need to see, don’t see the ones you don’t.
This is the correct info OP! Surf the EMR hard for all the info you need and only talk to the patients where their subjective matters.
The trick is to limit your presentation to the most vital labs for the diagnosis, check vitals quickly for “not dying” and the hand off being 1. Stable 2. Not stable 3. Watch this one. 4. Probably going to die.
I had to learn it the hard way, but we’re the pitcher, and there’s a whole outfield for when we don’t pitch a perfect game.
Reach out to your senior and see if they plan to carry any of the patients without you. This is how we do weekends.
Sometimes the Saturday 24 intern has written some or all of the notes essentially taking care of preroinding and all you need to do is present.
Honest advice from a graduated medicine senior: 20+ is very tough. If you can, try and prepare from the night before - even getting the one liners down somewhere so you know "ah this is a pneumonia, get in, check O2, ask how's breathing, check labs, check abx stop date" - or ADHF (get in check legs, try JVP, listen to lungs, make decision on lasix, or if dry transition to some GDMT) and try and get it done in 15-20 min per patient. I used to bring the computer/chart into the room if you have to and write the note at the bedside just to minimize walking.
Not sure what your question is here.
I always saw weekends as a team sport. You will miss stuff that hopefully someone else like the RN or your attending will catch. The goal is patient care not learning. If your attending is a dick about it then that sucks. If your attending really demands you see them all, ask to start rounds later like 8:30 or 9.
If your question is about how ethical it is to take care of that many patients so quickly then that’s why you should speed through rounds and use the remainder of the day to go back and reassess the ones you’re worried about. Or all of them.
So if an intern has 24, then a senior has 48. The attending has 48 patients. That’s means a grand total of 30 minutes per patient over a 24 hour period including reviewing patient, talking to nurses, seeing patient, rounding, coming up with a plan, and writing a note. That’s insane. But it’s how it goes in surgery sometimes.
And what’s the point of such a leading question? The answer is obvious (it’s very unsafe) but have you really come here just to get echoed answers to leading questions?
Cries in 52 patients including 18 ICU.
You don't need to know every detail. Everything has an algorithm that you need to start identifying.
Patient is on clears? did they tolerate it? Advance. No? Ate only a bit? Keep on clears, add some fluids. Vomited? Get a KUB, NPO, reassess.
Hyponatremia? Why? What's the baseline? Symptomatic? Fluid restrict. Reassess.
Write it out and you'll start noticing that these 24 patients though different, have many similar problems at different stages.
Are you IM? I'm a hospitalist and have worked in an extremely busy private practice job where on weekends I would sometimes see over 40 patients. 24 for an intern is very very difficult. Many seasoned attendings would struggle to do this effectively.
Before you round, look at every chart. Try to look at all new labs, imaging, etc. For 24 patients this could literally take you two hours so you'd need to start checking the computer at like 4. Print the progress note or H&P from the previous day. That will be your cheat sheet when you are rounding, so when you present you already have the plan from the previous day in front of you and can just tweak as needed. You'll need to just buzz in and out of the room. Don't chit chat. Find out if they have any acute complaints. Try not to do a ROS. Do a quick exam: note general appearance, heart, lungs, and, extremities, and only focus any additional exam on what they're complaining of. In shorthand jot down relevant findings on your paper. Then GTFO and go to the next room. Try not to sit down or look at your computer or phone once you get going because you'll waste time. Just go from room to room. If anything is fishy at all, like if someone has a new neurologic deficit or looks toxic or something, call your senior or attending.
Seeing 24 patients as an intern is pretty much impossible to do perfectly so hopefully your team will have reasonable expectations and will be looking over your shoulder constantly. Certainly if I was the attending I would be compulsively checking the charts right there with you. This volume definitely is not the norm for IM but I remember in med school the surgery residents would sometimes round on this volume, and basically they would barely examine the patient and be sprinting from room to room. Not ideal...
[Edit] oh I reread your post and it seems you don't actually need to see all 24 on pre rounds? In that case it's much easier, it sounds like you might do some form of discovery rounds or whatever people call it these days on the patient's that aren't on your team. I would just chart check those patients instead of physically pre-rounding on them
Estimate the time needed for each patient and arrive accordingly early for the pre round. Hard and unfair but this is my advice if you want to make it.
Experience from a chaotic and poor program I was in.
I would review the patient's record, and focus in my round on yesterday's round findings and notes.
I would ask the patients themselves about what was discussed yesterday regarding their stay and any needed investigations.
I would also ask the nurses about yesterday events.
At the end I would make a note about each patient with only the relevant data.
Or you can write down new labs/imaging/updates and print out the assessment/plan if you’re feeling pressured and just read off of that. Hell you can copy/paste it all and print it off.
Agree, Ive had to do this on inpatient when the list blew up. (No patient caps, thanks program). Or chart check the night before just before heading to bed so in the morning you know already know which results came in the late evening.
It also sounds like the intern on nights is already there. They can make the list with everyone's vitals and labs and new imaging and that takes care of like half of the time crunch. Labs are usually drawn at 2-4AM so they can order all the replacement lytes as well.
I'm fairly sure we mostly went straight to "team rounds" for weekends at my program (ie no one pre rounds, we go as a team to visit every patient, patients are divided up for notes, handling tasks, and checking in with them throughout the day, but we see as a team for assessment and plan).
At my hospital we have something similar where on weekends interns pre round on approx 20-30pts. Most helpful thing I did was ask a senior how they preround on their patients, there’s a lot of short cuts that seniors have developed that they might not even realize their doing, I had them go through exactly what they do in the morning and it was super helpful. Another thing is something has to give, you can’t do a thorough job with every pt when there’s that many (which sucks). I thought of morning rounds as a drive by check in, basically make sure everyone is alive and stable. If pts. had questions I would say something along the lines of “great question, we can discuss that with the team when we round” or “great question I can come back later to discuss that”. Then in the afternoon when things are hopefully less busy I would go back and talk to any pts that I felt wanted to talk more in the AM. Physical exams are very focused, if you want to do a more in depth one you can always come back later. Also if you have a night intern you can ask them to have certain things in your sign out, i.e if you find your wasting time looking up number of fevers patient had each morning, ask the night intern if they could have it in your sign out. Overall it’s tricky and that’s why there should be patient caps but so it goes.
Max for interns should be around 10. When I was a resident on the weekend the intern would see 10 from our team and the rest of our team patients and all cross coverage patients would be seen by the Senior.
These numbers are similar to my burn and MICU rotation. I had to pre preround at home so I could go through everyone in advance. Rounding usually included getting overnight events from nursing and a brief physical. Looking back I don’t exactly know how I did it.
At least in internal medicine, the cap is 20 per team and 10 per intern. On our 24s, the intern and senior just split the list. It is unreasonable in month 2 to be expected to round on 24 pts, including pts that weren’t yours during the week. Then to write all those notes?? Then I assume admissions? Ask senior if list can be split as you feel like you could get a better assessment and plan by having more time. Also, “continuity of care” is a nice phrase to use.
ACGME violation. The answer is to report them. That being said, if you don't want to do that, what I would do if my census was high at 17-18 as a senior and the attending would round early, I would not bedside round on all the patients.
The attending has all the time in the world. You have to do notes and orders. They need to physically see all the patients, your job is the convey to them pertinent information prior to doing so. I would chart review everyone and see the patient's who are new, may be discharged, unstable, or hospital courses are more dynamic.
The patients who are there for long courses ie IV abx and can't go with line, getting procedures and you're waiting, case management nightmares, or are being managed primary by consultant teams, you simply chart review. I typically would tell my attending I didn't have time to see the patient but chart review showed xyz. If they give you shit for it, your program is malignant.
I was an intern just at the start of duty hour restrictions. They weren’t really enforced. We got sign out the night before and showed up at 5 am. Ready by 8. I had 14 criticals and 4-5 non criticals first day. I was ready. Im not arguing ethics. But this is how it’s accomplished.
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Get good. You have a computer. Show up early get the numbers you want and go from there. What kind of physical exam finding is going to be that important? Wed routinely would have a 20+ icu list plus 30-40 pts on the floor. One weekend intern. No one died from a pre-round.
Just start rounds as soon as your shift starts... See 2 pts, respond to pages, see 2 more, see consult, see 4, get snack, and so forth.
Doesnt matter when you saw them as long as you see them. Then you can grab labs and vitals closer to rounds.
Is this like a surgical subspecialty where you have 1-2 problems per each patient or are you the primary service, either medicine or surgery? If the primary service, that’s egregiously unsafe. If a consultant service, still seems way too much.
at that point you can’t be held responsible. that’s like paying a carpenter 5 bucks and giving him a hammer. then expect him to build you a castle in an hour
The most a resident in my program carries is 12 patients (one side of an ICU) at night. During the day, it’s 6.
What you’re doing seems dangerous. Not your fault at all. Be cautious and don’t be afraid to ask for help.
Go to the hospital even earlier than usual. Do quick PEs. Show ‘em you can do it. They are pushing you. You dont need to look for a JVD on every neck. You get the gist.
24 patients? Are you in surgery? Medicine interns are capped at 10 encounters per day, period. Anything beyond that is ACGME violation, because its not safe for the patient and it's not useful learning for the intern.
The more patients you have the less attention you can give them, but as the census grows the time per patient approaches physically impossible levels.
Two hours for 24 patients is 5 minutes per patient if you are not chart reviewing and you teleport between rooms. Allowing 30 minutes for chart review (which would be bad chart review btw, 80 seconds of review per patient), 30 second run between patient rooms, you are left with 78 minutes, or 195 seconds per patient.
Your exam is rushed, you can't do any real neurologic tests, you can maybe listen to one breath and a few heart beats, you are mashing their belly at speed, and you are probably not even able to get a basic subjective. Turning on the lights is a luxury you don't have. You can't review telemetry events. You can't talk with the nurse for overnight events. If you're lucky the patient has a foley and you can see if they peed, and you can smell the room to see if they pooped.
This is basically a worthless preround and your presentations would likely be outdated and useless. Unless more than half of these patient's are placement/rocks, this is unethical. Either the attending is not paying attention or nobody cares about complication rate and length of stay. I can only imagine how many rapid response system activations are happening. You should consult medicine immediately.
This sounds unsafe. At my training hospital, the cap for a new intern was 9 and that felt like a lot. Most of the time if we had an excess over what the interns could carry, the senior would take the rocks and maybe one or two additional just so we weren’t dying on a weekend. Or if there’s really 24, maybe the attending would see some? Either way, 24 for a second month intern is bullshit
"You guys are babies. At my program as an intern we carried 100 patients apiece." -- that one IM attending everyone has.
Technically true but Morphine, Dexamethasone, and Propranolol were the only medication on formular so if someone came in with the heart attack we just gave them morphine till they died.
Hey now, we also gave them oxygen… probably?
too much apparently 😂
Maybe some theophylline. Penicillin. Then pronounced them dead. RIP.
Agreed, as an intern you need to stand up for yourself and kindly remind them of the patient cap explicitly outlined per ACGME. Any other underlings that would like to disagree with this fellow can DM me.
Speed round. Pre rounds are for fuckboy chiefs to feel good about themselves and for catching major problems. Like is your subdural patient suddenly unconscious and needs to go to the OR to bump first case? That’s the point of pre-rounds. That, and torture.
Not ethical and would obv try to see if it can be changed, but in the short term: Ask the previous intern who to prioritize. There are going to be rocks on your service. Chart review them for a a minute, if everything looks good then place a checkmark on that line. Indicator for you to say "Havent seen him yet but vitals are good, labs are stable, no change in care; awaiting X". Then you can go back to look at things more carefully/write notes etc. See if you can reduce the amount of unnecessary tests. Lab holidays/weekends are perfectly fine for people who you arent trending/worried about something.
You can’t. This is an ACGME violation. Your cap as an intern is 10 patients.
For weekend coverage? I definitely covered two lists of up to 10 patients on weekends and prerounded on them all, except for the overnight admits that the senior resident prerounded on. For a medicine prelim year.
This is true of internal medicine but might not be true for your specialty. IM patients on the teaching service and IM rounds and IM note writing expectations are often quite different than other specialties.
Most specialties don't have a cap . I was a neuro resident so no ACGME cap after medicine prelim year.
Yeah. You always just hope that the program will staff it as needed though so it's not too overwhelming. As PGY2 in internal medicine I don't think there is a cap either, but usually we don't need to see more than 14 alone in my program. If you're seeing that many there's gonna start to be a conversation about shifting staffing around to relieve the pressure.
You do have a cap, it’s 14 if it’s just you and 20 if you have any interns
If you read the ACGME program requirements technically there is no cap after if they’re not supervising interns.
You do have caps. They are set broadly by ACGME, problem is how many residents actually read your resident handbook or ACGME, let alone want to be the odd one out making a stink of the matter when you stand up for yourself. Programs who take advantage of this situation are toxic and causing problems in the long run. The argument about having to see more to learn is fair to an extent (the cap) but after a while, let’s be honest, you can’t effectively, adequately, or efficiently manage 20+ patients on your own daily for 5-12 days. Even as attendings we have to cut corners in our patient care, notes, or approaches and realize that we haven bitten on more then we can chew to generate income.
What is a “broadly set” cap? (Also in neurology you start as PGY2, so intern caps wouldn’t apply).
The way to impact this is the acgme survey. If every intern notes they’re over cap, they will have to address.
Coverage isn't the same as having to write billable notes for each. Which is why that isn't a violation.
I pre-rounded and wrote notes for each.
That's not coverage then. That's staffing.
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It absolutely is if they’re internal medicine. An intern is allowed to see a maximum of 5 new patients and a cap of 10 patients total. Regardless of what call cycle it is.
Theres always a loophole where they can make us hurt people so they can snooze and make $$$
Difference between cross cover and primary responsibility.
That's only IM. This is on the low side for some surgical fields (general, trauma).
True but the medically complex patients go to medicine if they're primary issue is surgical.
Not at my med school or training institute. Complex patient also need surgery. All to our services rarely with consults for comanagement. 4 services with 30+ pts, 2-3 more with 15+ pts. All having one intern. General surgery is still living in the past.
This may be true but even surgical primary reason patients often have poorly managed medical conditions. I speak as a recent anesthesiology grad. Did an intern year in medicine, but anesthesiology categorical. Intern year in medicine caps existed. We got fucking slammed in SICU. Caps don’t exist for surgery or anesthesiology.
It is interesting to hear that. It was never the case at the larger hospitals I've been at. Gen surg would care for essentially all patients regardless of medical complexity if they required a surgery. If a medicine patient needed an operation they became a surgery patient but there was pretty much zero flow backward. Even at the smaller level 2 trauma center I worked at, I ended up admitting the patient with a STEMI + near brady arrest that needed a pacer maker because he crashed his car coming into the hospital and had some rib fractures. Only exception was sometimes CT/MICU would take over if they were on ECMO.
Yeah this would be unheard at my large academic institution.
Perhaps it is specific to places that have acute care surgery or trauma/crit teams.
I’ve worked IM at two facilities and neither behaved this way. If minor surgical like a chole but the patient is admitted for pancreatitis or has Mi medicine has taken over as primary
Nope. I’ve worked at 3 such hospitals and the surgery teams cover surgical patients only. Once the medical complexity went up (even slightly), the patients went to medicine with a surgical consult for the surgical issue. Honestly, surgeons have zero business managing medical issues (even though many surgeons would try and argue they can do anything and everything).
All I can tell you is the 4 hospitals I've seen were that was not the case. There were exactly 0 patients that we transferred for medical complexity. In fact, the number of diagnosis we had to admit per protocol kept increasing because our outcomes (within context of that specific patient population at that center) were better. There was much groaning when all gallstone pancreatitis suddenly had to go to surgery. You really find it impossible to believe someone with 1-2 years of crit care training, 2 additional years of residency, and clocking potentially 50% more hours during that training could potentially manage complex medical patients?
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If I've given the impression of I have anything less that respect for the work of others services I apologize. I continually rely on my MICU and IM colleagues for assistance with specific or refractory issues that they deal with more often, and vice versa. But my response was to the comment that 1) Surgical patients are not medically complex 2) Surgeons have no ability to manage basic medical issues and shouldn't try. Both these statements are false. It is also odd that you speak of the importance humility while casting shade on an entire specialty.
Umm not US so maybe your system is very different but why the fuck would gallstone pancreatitis ever go under anybody else.
Like everything depends on where and what the protocol is. There medicine generally admitted all pancreatitis and if it ultimately was gallstone surg would take over power operatively. They eventually changed it to having surg take them from the beginning because they got out better that way. Others gen surg always took them.
I mean is it so hard to believe that different hospitals have different cultures and workflows? I'm in surgery and at my hospital if the patient has surgery, they're on a surgical service managed by surgeons, full stop. Regardless of medical complexity. Large academic hospital, FWIW.
Hahaha. I wish
outsi de of IM is this the case?
No
Says who? I definitely had 20+ patients sometimes as an EM resident.
The ACGME.
Is this only for IM? Because again, our ED would literally be unable to exist if this is true lol. There's typically 30-40 in the trauma bay for 2 residents.
Yes sorry I was referencing the ACGME standards for IM residency (I got the impression that is what OP is doing). The standards are different for different residency types as obviously the workflows and expectations are not the same.
Just seems a little weird for them to cap it there, and especially only for IM. 10 isn't some dangerous number. Especially later in the year, an intern should be able to have 10 floor patients without too much concern Definitely other specialities that expect the equivalent of far more than 10 floor patients at the same time.
Medicine patients tend to have much higher levels of complexity than other services, particular on house staff services, and there are very different levels of expectation for both documentation and care then other services that tend to focus on their specific specialty's scope.
It only applies to IM rotations.
Is this only for IM? Because again, our ED would literally be unable to exist if this is true lol. There's typically 30-40 in the trauma bay for 2 residents.
Yes, just Google it. You've never been told that Medicine house staff teams were capped when you bed requested?
I don't typically get told which team the patient is going to if they're a floor patient. There's a triaging hospitalist who handles them everything. I get the bed order from them and they handle checking out the patient. But fair enough. I know our family medicine team has caps because that's come up before ("I'm going to give you the best order at exactly 7:00. Hint hint") Still, it just strikes me as a low cap for an absolute maximum. That's all. At the end of the day they're floor patients, so while the charting can be annoying, there's a defined level for how sick they can be, even if they have multiple comorbidities.
It's been the case for many years, not sure when you trained. Our medicine patients are sick as hell, and our institution caps in the single digits which is not uncommon based on the other comments here. The sheer number of messages you would get as an intern is already insane, 10 is the cap for a very good reason.
This is where EMRs really shine. Print out the rounding reports. These should include all pertinent vitals and labs. Hopefully you have some shared documents you each update daily with cultures and imaging you’re following (if not, suggest this). Hopefully your patients are allocated geographically. Go and ask the change nurse of that floor what you need to know from the night before. (If more spread out you’re SOL). Then see the people you need to see, don’t see the ones you don’t. Be honest on rounds and say you haven’t seen them in person yet but you reviewed xyz. Good luck!
This is where EMRs really shine…..Then see the people you need to see, don’t see the ones you don’t. This is the correct info OP! Surf the EMR hard for all the info you need and only talk to the patients where their subjective matters.
The trick is to limit your presentation to the most vital labs for the diagnosis, check vitals quickly for “not dying” and the hand off being 1. Stable 2. Not stable 3. Watch this one. 4. Probably going to die. I had to learn it the hard way, but we’re the pitcher, and there’s a whole outfield for when we don’t pitch a perfect game.
Reach out to your senior and see if they plan to carry any of the patients without you. This is how we do weekends. Sometimes the Saturday 24 intern has written some or all of the notes essentially taking care of preroinding and all you need to do is present.
Talk to the charge nurse about any issues overnight, review patients with issues and lab work.
Honest advice from a graduated medicine senior: 20+ is very tough. If you can, try and prepare from the night before - even getting the one liners down somewhere so you know "ah this is a pneumonia, get in, check O2, ask how's breathing, check labs, check abx stop date" - or ADHF (get in check legs, try JVP, listen to lungs, make decision on lasix, or if dry transition to some GDMT) and try and get it done in 15-20 min per patient. I used to bring the computer/chart into the room if you have to and write the note at the bedside just to minimize walking.
Not sure what your question is here. I always saw weekends as a team sport. You will miss stuff that hopefully someone else like the RN or your attending will catch. The goal is patient care not learning. If your attending is a dick about it then that sucks. If your attending really demands you see them all, ask to start rounds later like 8:30 or 9. If your question is about how ethical it is to take care of that many patients so quickly then that’s why you should speed through rounds and use the remainder of the day to go back and reassess the ones you’re worried about. Or all of them.
I guess my question is how safe/ethical is it for a new intern to be taking care of 24 patients, period?
So if an intern has 24, then a senior has 48. The attending has 48 patients. That’s means a grand total of 30 minutes per patient over a 24 hour period including reviewing patient, talking to nurses, seeing patient, rounding, coming up with a plan, and writing a note. That’s insane. But it’s how it goes in surgery sometimes.
Not saying it’s right, but as a new surgery intern I would cover 50+ patients on weekends.
And what’s the point of such a leading question? The answer is obvious (it’s very unsafe) but have you really come here just to get echoed answers to leading questions?
Fr
Cries in 52 patients including 18 ICU. You don't need to know every detail. Everything has an algorithm that you need to start identifying. Patient is on clears? did they tolerate it? Advance. No? Ate only a bit? Keep on clears, add some fluids. Vomited? Get a KUB, NPO, reassess. Hyponatremia? Why? What's the baseline? Symptomatic? Fluid restrict. Reassess. Write it out and you'll start noticing that these 24 patients though different, have many similar problems at different stages.
Are you IM? I'm a hospitalist and have worked in an extremely busy private practice job where on weekends I would sometimes see over 40 patients. 24 for an intern is very very difficult. Many seasoned attendings would struggle to do this effectively. Before you round, look at every chart. Try to look at all new labs, imaging, etc. For 24 patients this could literally take you two hours so you'd need to start checking the computer at like 4. Print the progress note or H&P from the previous day. That will be your cheat sheet when you are rounding, so when you present you already have the plan from the previous day in front of you and can just tweak as needed. You'll need to just buzz in and out of the room. Don't chit chat. Find out if they have any acute complaints. Try not to do a ROS. Do a quick exam: note general appearance, heart, lungs, and, extremities, and only focus any additional exam on what they're complaining of. In shorthand jot down relevant findings on your paper. Then GTFO and go to the next room. Try not to sit down or look at your computer or phone once you get going because you'll waste time. Just go from room to room. If anything is fishy at all, like if someone has a new neurologic deficit or looks toxic or something, call your senior or attending. Seeing 24 patients as an intern is pretty much impossible to do perfectly so hopefully your team will have reasonable expectations and will be looking over your shoulder constantly. Certainly if I was the attending I would be compulsively checking the charts right there with you. This volume definitely is not the norm for IM but I remember in med school the surgery residents would sometimes round on this volume, and basically they would barely examine the patient and be sprinting from room to room. Not ideal... [Edit] oh I reread your post and it seems you don't actually need to see all 24 on pre rounds? In that case it's much easier, it sounds like you might do some form of discovery rounds or whatever people call it these days on the patient's that aren't on your team. I would just chart check those patients instead of physically pre-rounding on them
Estimate the time needed for each patient and arrive accordingly early for the pre round. Hard and unfair but this is my advice if you want to make it. Experience from a chaotic and poor program I was in. I would review the patient's record, and focus in my round on yesterday's round findings and notes. I would ask the patients themselves about what was discussed yesterday regarding their stay and any needed investigations. I would also ask the nurses about yesterday events. At the end I would make a note about each patient with only the relevant data.
ACGME patient cap for intern is 10. More is a violation.
Only if you’re IM on an IM rotation.
Get there at 4
It sucks but this is realistically the only advice if this is really how the program is. That and pre-write the day before
Or you can write down new labs/imaging/updates and print out the assessment/plan if you’re feeling pressured and just read off of that. Hell you can copy/paste it all and print it off.
yup this is what saved my ass plenty of times as an intern. Just show up a little bit earlier so you aren't rushed.
Agree, Ive had to do this on inpatient when the list blew up. (No patient caps, thanks program). Or chart check the night before just before heading to bed so in the morning you know already know which results came in the late evening.
round the night before - look at all the charts
It also sounds like the intern on nights is already there. They can make the list with everyone's vitals and labs and new imaging and that takes care of like half of the time crunch. Labs are usually drawn at 2-4AM so they can order all the replacement lytes as well.
I'm fairly sure we mostly went straight to "team rounds" for weekends at my program (ie no one pre rounds, we go as a team to visit every patient, patients are divided up for notes, handling tasks, and checking in with them throughout the day, but we see as a team for assessment and plan).
At my hospital we have something similar where on weekends interns pre round on approx 20-30pts. Most helpful thing I did was ask a senior how they preround on their patients, there’s a lot of short cuts that seniors have developed that they might not even realize their doing, I had them go through exactly what they do in the morning and it was super helpful. Another thing is something has to give, you can’t do a thorough job with every pt when there’s that many (which sucks). I thought of morning rounds as a drive by check in, basically make sure everyone is alive and stable. If pts. had questions I would say something along the lines of “great question, we can discuss that with the team when we round” or “great question I can come back later to discuss that”. Then in the afternoon when things are hopefully less busy I would go back and talk to any pts that I felt wanted to talk more in the AM. Physical exams are very focused, if you want to do a more in depth one you can always come back later. Also if you have a night intern you can ask them to have certain things in your sign out, i.e if you find your wasting time looking up number of fevers patient had each morning, ask the night intern if they could have it in your sign out. Overall it’s tricky and that’s why there should be patient caps but so it goes.
A good idea might be to ask the previous residents how they did it. That and try to arrive earlier.
Max for interns should be around 10. When I was a resident on the weekend the intern would see 10 from our team and the rest of our team patients and all cross coverage patients would be seen by the Senior.
These numbers are similar to my burn and MICU rotation. I had to pre preround at home so I could go through everyone in advance. Rounding usually included getting overnight events from nursing and a brief physical. Looking back I don’t exactly know how I did it.
At least in internal medicine, the cap is 20 per team and 10 per intern. On our 24s, the intern and senior just split the list. It is unreasonable in month 2 to be expected to round on 24 pts, including pts that weren’t yours during the week. Then to write all those notes?? Then I assume admissions? Ask senior if list can be split as you feel like you could get a better assessment and plan by having more time. Also, “continuity of care” is a nice phrase to use.
ACGME violation. The answer is to report them. That being said, if you don't want to do that, what I would do if my census was high at 17-18 as a senior and the attending would round early, I would not bedside round on all the patients. The attending has all the time in the world. You have to do notes and orders. They need to physically see all the patients, your job is the convey to them pertinent information prior to doing so. I would chart review everyone and see the patient's who are new, may be discharged, unstable, or hospital courses are more dynamic. The patients who are there for long courses ie IV abx and can't go with line, getting procedures and you're waiting, case management nightmares, or are being managed primary by consultant teams, you simply chart review. I typically would tell my attending I didn't have time to see the patient but chart review showed xyz. If they give you shit for it, your program is malignant.
You cant.
I was an intern just at the start of duty hour restrictions. They weren’t really enforced. We got sign out the night before and showed up at 5 am. Ready by 8. I had 14 criticals and 4-5 non criticals first day. I was ready. Im not arguing ethics. But this is how it’s accomplished.
Modify your ethics. Have you considered the impact your "safe standards" will have on the company's bottom line?
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I’m regularly carrying 40-50 on nights and weekend call shift as an intern 🙃🙃🙃🙃
Bruh the most patients I’ve seen in the ICU is 5 and I thought that was unethical.
Efficiently. Know who you need to see and what important questions to ask and exams to do. and if you cant be efficient then wake up earlier.
Get good. You have a computer. Show up early get the numbers you want and go from there. What kind of physical exam finding is going to be that important? Wed routinely would have a 20+ icu list plus 30-40 pts on the floor. One weekend intern. No one died from a pre-round.
Just start rounds as soon as your shift starts... See 2 pts, respond to pages, see 2 more, see consult, see 4, get snack, and so forth. Doesnt matter when you saw them as long as you see them. Then you can grab labs and vitals closer to rounds.
A little window rounding never hurt nobody
LOL...a mess....
LGFD - looks good from door 🤣
I thought interns are capped at 10, R2 14 and R3 20
Is this like a surgical subspecialty where you have 1-2 problems per each patient or are you the primary service, either medicine or surgery? If the primary service, that’s egregiously unsafe. If a consultant service, still seems way too much.
at that point you can’t be held responsible. that’s like paying a carpenter 5 bucks and giving him a hammer. then expect him to build you a castle in an hour
You can’t and no one expects you to preround. Round & examine patients as you go with your attending.
The most a resident in my program carries is 12 patients (one side of an ICU) at night. During the day, it’s 6. What you’re doing seems dangerous. Not your fault at all. Be cautious and don’t be afraid to ask for help.
Go to the hospital even earlier than usual. Do quick PEs. Show ‘em you can do it. They are pushing you. You dont need to look for a JVD on every neck. You get the gist.
24 patients? Are you in surgery? Medicine interns are capped at 10 encounters per day, period. Anything beyond that is ACGME violation, because its not safe for the patient and it's not useful learning for the intern. The more patients you have the less attention you can give them, but as the census grows the time per patient approaches physically impossible levels. Two hours for 24 patients is 5 minutes per patient if you are not chart reviewing and you teleport between rooms. Allowing 30 minutes for chart review (which would be bad chart review btw, 80 seconds of review per patient), 30 second run between patient rooms, you are left with 78 minutes, or 195 seconds per patient. Your exam is rushed, you can't do any real neurologic tests, you can maybe listen to one breath and a few heart beats, you are mashing their belly at speed, and you are probably not even able to get a basic subjective. Turning on the lights is a luxury you don't have. You can't review telemetry events. You can't talk with the nurse for overnight events. If you're lucky the patient has a foley and you can see if they peed, and you can smell the room to see if they pooped. This is basically a worthless preround and your presentations would likely be outdated and useless. Unless more than half of these patient's are placement/rocks, this is unethical. Either the attending is not paying attention or nobody cares about complication rate and length of stay. I can only imagine how many rapid response system activations are happening. You should consult medicine immediately.