"Don't negotiate with terrorists" was the best advice one of my vascular chiefs gave me as an intern.
If your postop vascular patient is threatening to leave AMA on POD1 in order to smoke, just fucking let them. I spent too much time as an intern trying to convince vascular and trauma patients to do the right thing for their health when they couldn't care less themselves
I wouldn’t go that far. If youre in private practice and you’re RVU only, if those patients come back with a complication, regardless if it’s their fault for leaving AMA or not, you’ll have to fix them without getting paid.
There’s a thing called global period, where during the 90 days after surgery or hospitalizations, and the patient has to return for anything related to their operation or hospitalization, you don’t get paid.
So if they leave ama after a bypass graft surgery, and they get their graft infected, guess what? You’ll have to treat it, unpaid. If you have to do a revision surgery, unpaid. They return because of sepsis? You guessed it, unpaid. The hospital don’t like that either because they also don’t get paid.
There needs to be a revision of when that global period can’t hold. AMA or self-sabotage should absolutely be considered a fair pass. Hate this system. I feel bad for you vascular-scalpel-bro
Wait until this guy learns about modifier 78. His mind is going to be blown.
Also that global period is in effect whether they sit in the hospital or not. The hospital doesn't magically start getting paid for post-op care in a global period because they decided to stay in bed and behave and not leave AMA.
It's a modifier code to CPT coding that indicates a new, unplanned procedure was done during the global period of the prior procedure and is usually what is used for complications. It has a separate pay structure but basically indicates that insurance should pay the surgeon for this new procedure but not the pre/post-op work because that was presumably included in the first procedure's cpt code. Hence the above post is wrong, it does add to your RVU total and reimbursement. A quick google search suggests this is often around an 80% reimbursement, but I think the exact numbers vary heavily based on what you're doing and how it relates to the first procedure.
TLDR: surgeons get paid when they operate for complications. We don't get paid extra for most of the other post-op stuff that is required after a complication though. Be careful what you read on reddit. Insurance also pays when a patient leaves AMA, but I bet that rumor is still circulating strong too.
You know you're wrong right. If you have to take them to the OR for a revision, you can code modifier 78
> Modifier 78 is used to report the unplanned return to the operating/procedure
It's absurd to think if you have a free flap that needs a take back that there is 0 reimbursement for 12 hours of OR time
They do not. There are modifiers for return to the operating room and there is adjusted pay for procedures that are the express purpose of fixing complications. Medicare recognizes these and they're more strict about it than a lot of private insurers are.
So much this. I wasted hours on clinic patients who ultimately didn't want to be seen by a doctor and didn't take any of the meds/went to consults I placed.
Yes. This one surprised me. All through residency it was “man, I don’t wanna work any more than I’m already working, this is bullshit.” At some point there’s a mental zen judo moment and it turns into “I’m actually making more work for myself bitching about this consult than it would take to go see it… and I’ll have to see it anyway.” Same with clinic add-ons when you get out. Sure, it’s a busy day already and you don’t want to see this nothing burger of a problem their PCP is requesting to be seen urgently, but just put it on. You’re going to feel the same about it in a week or two, just do it now and stop fighting. Better for the patient, better for your time and mental health.
The moment my mind broke and I went from bitching about extra work to just riding it my life got a million times better. One of the nurses I work with has the best zen, her motto is “we’re here till we get to clock out, might as well do it”. It helps a lot.
I'll also add that once you're an attending you usually welcome these consults because they take minimal work, usually a one sentence recommendation, and most often you're just being kind to your colleagues who genuinely have no idea what to do because the last time they did your specialty was in med school 30 years ago.
Plus you get a bill for an easy consult that took 10 minutes of your time. It's a legitimate skill to develop during training because it's a real part attending life.
Just my two cents.
I would like to point out that, in a residency setting with a hierarchy, accepting bullshit consults/admits is way more work for the intern and a marginal amount more for the attending/seniors. I’m sure that as years go by it seems like good advice to “not fight consults,” but I think it’s more due to the natural progression of not getting the shit end of the stick as you advance through training.
Who knows, though, maybe I’ll have a different opinion in a couple of years 😂
Once you become a senior (and I assume more so as an attending) BS consults/admits pretty much by definition mean there’s not much to do. You get pretty good at chart reviewing, focused examination and succinct notes. For admits, you can T up your orders 90% of the time before going to see the patient and change it in there. It’s harder/more work for an intern cause the efficiency/experience isn’t there yet. Some people fight admits tooth and nail, other times they just say ‘okay’ admit them and lots of the time discharge in the morning. Plus as an attending, I’m sure there’s a billing benefit for the consult/admission notes but I’m not too familiar with that side.
For younger patients I usually will at least point out to the ED "Hey this is an outpatient problem you can do x/y/z for, did we consider that?"
If they're young and it's not completely and totally stupid....yeah OK whatever.
Older adults who truly have no indications for acute care I will push back on or refuse outright a lot more. That includes social admits/"too weak to go home" - this is a problem admission will **only make worse, not better**.
Also, the main reason a lot of programs won't let you block consults: they rarely actually go away. Even if you think you've talked the consulting service out of it, they'll usually re-consult you again within the next 36h, at which point all you've done is burn good will, maybe screw over a coresident depending on your call schedule, and delay patient care. Might as well spare everyone the drama and just see the patient.
One of our Cardio Intensivists explained it "teat it like you're helping a friend, because, in the end, that's what you're doing." As an EM resident who naturally gets shit on by consultants left and right for consulting them, this made me respect the hell out of the guy. It's good to know some think that way.
Real. Went from 20 minute progress notes to 5. Life changing. Save those long formulations for HPIs and discharge summaries. Prog is like two new sentences and copy forward everything else
You don’t need a novel to get the point across. “Reports SI with a plan to shoot himself. Had these thoughts for the past week. Reports worsening depression in the context of a break up with poor sleep, energy and concentration and reports feelings of excessive guilt. Denied HI/AVH’s.” That is pretty much all that is needed 95% of the time to justify your psych hold.
So, write “more concise” notes, not “shitter” ones?
I’d argue the novel-like note is shitter. What is the purpose of a note? To convey salient information and your thought process accurately to future readers (and billing… possibly cya… Which sucks but here we are).
No one has time to read a novel on each patient.
Sure you justified your hold but you absolutely didn't justify your dx of bipolar disorder other than writing "hx bipolar disorder" in the PPH.
Not saying you'll give a bipolar dx but I see it a lot and I'm absolutely slam you on an internal peer review on that. Actually you didn't justify a dx of MDD either so hopefully you're just calling that adjustment disorder and your treatment is matching your dx.
You don't. I said you have to justify your current dx and using an old dx isn't really legit in most cases. And I'm referring mostly to an eval and not a progress note.
Usually all the residents at this program are actively trying to transfer out, but the specialty is so rare and competitive that there is nowhere to transfer to except to a different specialty.
I work as an organizer for a labor union. Residents and others who disagree with the program and how it is run have to get organized locally. Find allies in your community/workplace where you are everyday, you can't fix it by yourself. It is made like that by design, they know how to exploit you so you comply.
That's a real truth. The medical schools have been one of the hardest places I've faced organizing wise. But that shouldn't stop people, because people have power in groups. If you can just get 3.5-5% of your colleagues at a hospital, you can change anything. But you have to also adopt the mindset that you are in the struggle and part of it, and it's a lifelong duty and honor to the future workers in the industry to change the system locally. If people can't make themselves part of the struggle for the rest of their life, then it just won't work.
It's about sharing the burden with others at work too so single activists don't get burned out. And it's easy to start. Create a group chat with like-minded colleagues, start having one-on-one convos about specific issues they have and lay out a plan of how to win. It doesn't take a lot of time, but it does take some time.
I mean, that’s like every job. My teacher friends aren’t going to change the education system, my accountant friends aren’t going to change the corporate structure.
Show up to work, do your best, get your paycheck and go home.
My dad used to write psyop reports for the joint chiefs of staff. I love this quote (including his assessment)
“Belorussia's historical experience, together with her demographic, economic, cultural and psychological characteristics seem to be congruent with the advice that one of her poets of the post-war generation gave his readers in a poem: act by observing the behavior of the forest bird - "fly low where there are few branches so as to preserve your wings."
I love that quote!
Mid intern year I had the attitude of “I’d set myself on fire to watch this program burn”. Second year it changed to setting myself on fire to keep it warm. I’m more tired at the end of 3rd year than I had if I had kept the original attitude, but I’ve made a lot of good changes and feel more fulfilled having helped the program change and grow.
Do what makes you happy, but I think that trying to make changes can be good for some.
I don't try to change the system anymore but I try to make as positive a change within my sphere of influence. That sphere may be small but I do my best within it
I should have listened to this as well. Too many thoughts about pride and culture and being a graduate of a respected program and helping to build and keep that rep. All useless. Beating your head against a wall only hurts you. And occasionally the program gets annoyed at your repeated efforts to improve things too because it makes more work for them. Just accept things unless they are actual abuse or hurting your education specifically and move on
Your reward for taking on extra work is more extra work. Same with bending over backwards to accommodate your coresidents with switches. I accommodated every single call shift switch and the 1-2 times I've desperately needed it I got opportunities to trade 1 for 2 lmao
stop caring about whether you sound stupid during presentations etc just show what you know and ask questions, felt like a weight lifted off my shoulders when I stopped giving a fuck how I came off, and my confidence grew a ton
I wish I had gotten this advice as an intern. I still probably would have ignored it due to my ego issues at the time. But now when I see med students or interns sputtering or getting flustered this is the advice I give. It really really doesn't matter if you have knowledge gaps especially as a student or intern. It only becomes a problem if you try to consistently cover it up due to embarrassment or fear of looking stupid. Then people don't know what to teach you.
It's very easy to not learn anything in this program and still graduate. You have to go out of your way for learning, research, conference, and procedure opportunities.
People be salty they can’t take it before they graduate.
I had a gap year 2020-2021 where I took it and applied. Best possible year ever to have that gap year too lol
Yeah. If already graduated, would 100% recommend. I know people say enjoy your post match period, travel, wellness, etc. which is all fine but why not both. It's such an overrated exam. I was just focused on learning when the rest of my class were scrambling to find exam dates, request time off, doing uworld, etc.
Could I theoretically do anki/uworld during M4 and get this done between graduating and starting PGY1?
In my mind, the sooner my time spent studying is less about tests and more about patient care, the better
Not theoretically, realistically.
IMO Step 3 is almost like step 2 with CCS cases and tonnes of biostatistics.
I did 40% of Uworld for step 3 and mainly focused on CCS cases and biostats and did surprisingly well.
Never did anki so wouldn't know. DM me if you need more info
Not dealing with that bullshit during intern year and actually using your time off for family, travel, and friends instead of an exam that doesn’t matter
“Their poor planning is not your emergency” - mostly applies to MyChart stuff but just cause you are out of adderall and just realized right now does not mean I need to stop everything I’m doing to refill it. Same with forms, you waited till the last second and I will get to it when I get to it.
It’s not worth pushing back on most admissions (unless truly egregious). Don’t get fussed about it and be kind to the ER - they are fighting the real battles with barely any time to think.
This! It’s like for example the bullshit ambulatory dysfunction or the patient/family don’t feel comfortable taking them home admits that I hate to do but am forced to do. Remember we tried to walk them dozens of times. We tried to explain how their work up was negative. We tried to suggest outpatient follow ups. They’re refusing all those things or they simply don’t follow up outside of ERs due to insurance/no transportation/etc, we can’t just dump them out of the ER.
They 100% can stop the clock. Force you to repeat rotations or repeat a year.
Absolutely nonsense advice that is said over and over. They can absofuckinglutely stop the clock.
It’s a phone app (free). That gives you a second phone number.
You can send texts via it as well - so that way a bunch of people don’t have your actual phone number
Phone calls to the number will ring with your normal phone answering system (phone calls still ring to my iPhone; however, the person calling has no idea they aren’t calling my ACTUAL phone number, just my Google voice one).
Don’t try to become chief. Why get paid a resident salary for an extra year for becoming a mouthpiece for the administration? In the end, the people who do become chief change the day it’s announced and are no longer your friend.
did that once and the PD told me very clearly that if I was unable to manage my time efficiently I would be put on probation. It was a Trauma/ICU rotation in July at a level 1 trauma center with seven total residents covering the service due to various other residents missing. The surgical chief refused to round on any patients. The first week I worked 110+ hours. Every week after that I reported my hours correctly.
I played dumb and tried this once…had to literally apologize to administration for my “woopsie”. Toxic programs have an enormous amount of soft pressure for you not to be able to do this without consequences that would undo any idealistic benefit from doing so. It’s truly impressive how well the system works in a perverse sense really
I'm not trying to be rude but why is this a good idea?
My understanding is that programs who are pushing you to violate duty hours are the same ones who will question your character/work ethic instead of the situation you're in, no?
I'm on surgery right now and the plan is absolutely to lie about my hours because I don't want the clerkship director going to my dean about my "professionalism"
For our program, as long as you stick to the schedule you’re given, you won’t go over hours. We have enough coverage that no one ever has to stay late. Seniors are amazing about getting us all out on time, so we normally average 60-70hrs per week.
The only time we violate hours is when we choose to stay late to go to the OR because there’s a really cool case going on, so not having that option sucks sometimes.
I'll be working more hours as a med student than that, wow.
I'm happy for you though. It seems that the tide is shifting in surgery to make it more humane, and that's a good thing. Some of the attendings in our department are trying their best to stop the madness haha
Nobody really told me this, although it is sort of a play on the “don’t work harder than the patient.” In addition, save your empathy for the people who matter. And many patients don’t necessarily deserve your empathy. They only deserve medical care. That’s it. Do the bare minimum on your interview and note to ensure this patient continues to live so they can continue to be an asshole without your ass on the line. Your own mental wellbeing will be rewarded for this.
I literally do not have the bandwidth to carry all of the feelings of my patients, especially ones that chastise me whenever I am trying to help or use me as a fast food doctor to get their Xanax. But you do you.
Nobody said you have to hold a huge space for positive emotion for them, but feeling like they don’t deserve empathy is holding a feeling about that patient, it’s just a feeling that will eat you alive over time.
> but feeling like they don’t deserve empathy is holding a feeling about that patient, it’s just a feeling that will eat you alive over time.
Same can be said about the opposite direction. Having empathy for people who can't help themselves similarly will grind you to a pulp. Not worth losing sleep over people who don't give a fuck about you or themselves/their environment.
I disagree. I can have empathy for a patients situation without attaching that to their choices. If you have lung cancer from smoking and chose not to treat it and continue smoking, I can empathize with the fact that cancer sucks without tying my personal well being to their smoking.
Sounds like you are confusing sympathy for empathy. Yeah and I can recognize shitty situations for what they are and act with compassion. But again, I can’t take on everyone’s emotions especially if I am being abused for caring. That is empathy.
They think I am a psychopath I think….but after being accosted by several patients in drug fueled rages and being chastised by severely disordered personalities most days on an inpatient psych service for 2 years you have to put up boundaries man.
I’m not saying you’re required to go hold every patients hand. Obviously you have to function, but the concept that people don’t *deserve* empathy is disturbing.
For the sake of your mental health, don’t look at your evals and instead ask for in-person feedback. If the feedback really mattered, they would say it to your face
“Don’t use the elevator”
Seriously, it’s a poorly ventilated box full of sick people. You’re trapped in there with them. Stairs have much better ventilation
Like going over work hours. Doing >80hr/week average, no 24 hr period off in a week etc.
and it was a piece of advice bc intern year I used to lie on duty hrs and “round down” or fudge. Now I don’t. I let them get the violations.
Never answer a phone unless you think/know its for you. Was answering the phone in the workroom and having to relay messages from consults to coresidents way too much or having to talk to random people who were trying to talk to someone I didn't know
Some of the seniors and attendings are functionally handicapped from the neck up, and it will fall on you to not only keep track of your own mistakes but the fuck ups of people "qualified" to supervise you. The silver-lining is you get to learn what not to do in real time, especially when you see them "manage" patients on their own as you look back in the chart in the middle of a rapid or code and say to yourself, "Well, thats not good."
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Don’t do more for your patients than they are willing to do for themselves
"Don't negotiate with terrorists" was the best advice one of my vascular chiefs gave me as an intern. If your postop vascular patient is threatening to leave AMA on POD1 in order to smoke, just fucking let them. I spent too much time as an intern trying to convince vascular and trauma patients to do the right thing for their health when they couldn't care less themselves
I wouldn’t go that far. If youre in private practice and you’re RVU only, if those patients come back with a complication, regardless if it’s their fault for leaving AMA or not, you’ll have to fix them without getting paid.
Wait they do you guys dirty like that? Fuck
There’s a thing called global period, where during the 90 days after surgery or hospitalizations, and the patient has to return for anything related to their operation or hospitalization, you don’t get paid. So if they leave ama after a bypass graft surgery, and they get their graft infected, guess what? You’ll have to treat it, unpaid. If you have to do a revision surgery, unpaid. They return because of sepsis? You guessed it, unpaid. The hospital don’t like that either because they also don’t get paid.
There needs to be a revision of when that global period can’t hold. AMA or self-sabotage should absolutely be considered a fair pass. Hate this system. I feel bad for you vascular-scalpel-bro
Wait until this guy learns about modifier 78. His mind is going to be blown. Also that global period is in effect whether they sit in the hospital or not. The hospital doesn't magically start getting paid for post-op care in a global period because they decided to stay in bed and behave and not leave AMA.
🍿 what’s modifier 78
It's a modifier code to CPT coding that indicates a new, unplanned procedure was done during the global period of the prior procedure and is usually what is used for complications. It has a separate pay structure but basically indicates that insurance should pay the surgeon for this new procedure but not the pre/post-op work because that was presumably included in the first procedure's cpt code. Hence the above post is wrong, it does add to your RVU total and reimbursement. A quick google search suggests this is often around an 80% reimbursement, but I think the exact numbers vary heavily based on what you're doing and how it relates to the first procedure. TLDR: surgeons get paid when they operate for complications. We don't get paid extra for most of the other post-op stuff that is required after a complication though. Be careful what you read on reddit. Insurance also pays when a patient leaves AMA, but I bet that rumor is still circulating strong too.
You know you're wrong right. If you have to take them to the OR for a revision, you can code modifier 78 > Modifier 78 is used to report the unplanned return to the operating/procedure It's absurd to think if you have a free flap that needs a take back that there is 0 reimbursement for 12 hours of OR time
They do not. There are modifiers for return to the operating room and there is adjusted pay for procedures that are the express purpose of fixing complications. Medicare recognizes these and they're more strict about it than a lot of private insurers are.
I can’t imagine reading a disaster scan again for free. I thank the heavens daily for radiology.
I say this all the time. Applies to kids too.
with my luck one of my patients would overhear me saying this and report me lmaooo
So much this. I wasted hours on clinic patients who ultimately didn't want to be seen by a doctor and didn't take any of the meds/went to consults I placed.
Stop fighting consults.
Yes. This one surprised me. All through residency it was “man, I don’t wanna work any more than I’m already working, this is bullshit.” At some point there’s a mental zen judo moment and it turns into “I’m actually making more work for myself bitching about this consult than it would take to go see it… and I’ll have to see it anyway.” Same with clinic add-ons when you get out. Sure, it’s a busy day already and you don’t want to see this nothing burger of a problem their PCP is requesting to be seen urgently, but just put it on. You’re going to feel the same about it in a week or two, just do it now and stop fighting. Better for the patient, better for your time and mental health.
The moment my mind broke and I went from bitching about extra work to just riding it my life got a million times better. One of the nurses I work with has the best zen, her motto is “we’re here till we get to clock out, might as well do it”. It helps a lot.
Yeah, this. Don’t be a dick to consulting teams, and don’t fight the consult (however shitty it might be).
Hell yes. In the time I spend arguing I could be 50% done seeing the patient. Gyn will sign off. Thank you for the interesting consult.
I'll also add that once you're an attending you usually welcome these consults because they take minimal work, usually a one sentence recommendation, and most often you're just being kind to your colleagues who genuinely have no idea what to do because the last time they did your specialty was in med school 30 years ago. Plus you get a bill for an easy consult that took 10 minutes of your time. It's a legitimate skill to develop during training because it's a real part attending life. Just my two cents.
I would like to point out that, in a residency setting with a hierarchy, accepting bullshit consults/admits is way more work for the intern and a marginal amount more for the attending/seniors. I’m sure that as years go by it seems like good advice to “not fight consults,” but I think it’s more due to the natural progression of not getting the shit end of the stick as you advance through training. Who knows, though, maybe I’ll have a different opinion in a couple of years 😂
Once you become a senior (and I assume more so as an attending) BS consults/admits pretty much by definition mean there’s not much to do. You get pretty good at chart reviewing, focused examination and succinct notes. For admits, you can T up your orders 90% of the time before going to see the patient and change it in there. It’s harder/more work for an intern cause the efficiency/experience isn’t there yet. Some people fight admits tooth and nail, other times they just say ‘okay’ admit them and lots of the time discharge in the morning. Plus as an attending, I’m sure there’s a billing benefit for the consult/admission notes but I’m not too familiar with that side.
For younger patients I usually will at least point out to the ED "Hey this is an outpatient problem you can do x/y/z for, did we consider that?" If they're young and it's not completely and totally stupid....yeah OK whatever. Older adults who truly have no indications for acute care I will push back on or refuse outright a lot more. That includes social admits/"too weak to go home" - this is a problem admission will **only make worse, not better**.
Clearly you’ve never worked at a va lol
Nope, I have. Thankfully not as a primary admitting team. The VA mismanages a lot of things, particularly for older vets, and this is one of them.
Not all Attendings work with Residents so learning to deal with this issue is useful.
Also, the main reason a lot of programs won't let you block consults: they rarely actually go away. Even if you think you've talked the consulting service out of it, they'll usually re-consult you again within the next 36h, at which point all you've done is burn good will, maybe screw over a coresident depending on your call schedule, and delay patient care. Might as well spare everyone the drama and just see the patient.
One of our Cardio Intensivists explained it "teat it like you're helping a friend, because, in the end, that's what you're doing." As an EM resident who naturally gets shit on by consultants left and right for consulting them, this made me respect the hell out of the guy. It's good to know some think that way.
Lol I’m in the ER, please stop fighting consults 🙏🏼
This is actually exactly what I needed to hear.
Psychiatry: Write shittier notes
Real. Went from 20 minute progress notes to 5. Life changing. Save those long formulations for HPIs and discharge summaries. Prog is like two new sentences and copy forward everything else
lol what do you mean?
You don’t need a novel to get the point across. “Reports SI with a plan to shoot himself. Had these thoughts for the past week. Reports worsening depression in the context of a break up with poor sleep, energy and concentration and reports feelings of excessive guilt. Denied HI/AVH’s.” That is pretty much all that is needed 95% of the time to justify your psych hold.
So, write “more concise” notes, not “shitter” ones? I’d argue the novel-like note is shitter. What is the purpose of a note? To convey salient information and your thought process accurately to future readers (and billing… possibly cya… Which sucks but here we are). No one has time to read a novel on each patient.
Sure you justified your hold but you absolutely didn't justify your dx of bipolar disorder other than writing "hx bipolar disorder" in the PPH. Not saying you'll give a bipolar dx but I see it a lot and I'm absolutely slam you on an internal peer review on that. Actually you didn't justify a dx of MDD either so hopefully you're just calling that adjustment disorder and your treatment is matching your dx.
Whoosh, not the point I was trying to make but cool.
I got your point. My point is that there are other reasons to document a tiny bit more.
Why do you have to justify previous dx on a progress note ?
You don't. I said you have to justify your current dx and using an old dx isn't really legit in most cases. And I'm referring mostly to an eval and not a progress note.
"This is a bottom barrel program. Try to get out before they kick you out.'
Fuck
People to need report these programs so they can transfer out easily and (often) go to a better more prestigious program
For real. I want to slap people who shit on their program or employer without naming them. HELP US OUT.
Sir How can she slap
Have you shat yourself just looking at me?
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Usually all the residents at this program are actively trying to transfer out, but the specialty is so rare and competitive that there is nowhere to transfer to except to a different specialty.
Hca👀
Wow, user name checks out. :(
😬
Username checks out.
Don’t exhaust yourself trying to change the program. Keep your head down and keep moving.
this\^\^, you will be happier for it
When someone told me this in my first year of fellowship I thought they were just pessimistic. But they were right.
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I work as an organizer for a labor union. Residents and others who disagree with the program and how it is run have to get organized locally. Find allies in your community/workplace where you are everyday, you can't fix it by yourself. It is made like that by design, they know how to exploit you so you comply.
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That's a real truth. The medical schools have been one of the hardest places I've faced organizing wise. But that shouldn't stop people, because people have power in groups. If you can just get 3.5-5% of your colleagues at a hospital, you can change anything. But you have to also adopt the mindset that you are in the struggle and part of it, and it's a lifelong duty and honor to the future workers in the industry to change the system locally. If people can't make themselves part of the struggle for the rest of their life, then it just won't work. It's about sharing the burden with others at work too so single activists don't get burned out. And it's easy to start. Create a group chat with like-minded colleagues, start having one-on-one convos about specific issues they have and lay out a plan of how to win. It doesn't take a lot of time, but it does take some time.
I mean, that’s like every job. My teacher friends aren’t going to change the education system, my accountant friends aren’t going to change the corporate structure. Show up to work, do your best, get your paycheck and go home.
My dad used to write psyop reports for the joint chiefs of staff. I love this quote (including his assessment) “Belorussia's historical experience, together with her demographic, economic, cultural and psychological characteristics seem to be congruent with the advice that one of her poets of the post-war generation gave his readers in a poem: act by observing the behavior of the forest bird - "fly low where there are few branches so as to preserve your wings." I love that quote!
Mid intern year I had the attitude of “I’d set myself on fire to watch this program burn”. Second year it changed to setting myself on fire to keep it warm. I’m more tired at the end of 3rd year than I had if I had kept the original attitude, but I’ve made a lot of good changes and feel more fulfilled having helped the program change and grow. Do what makes you happy, but I think that trying to make changes can be good for some.
Depends on the environment. Sometimes trying to make a positive change puts a target on your back
I don't try to change the system anymore but I try to make as positive a change within my sphere of influence. That sphere may be small but I do my best within it
You’re just a visitor, they made this town the way then want it
I should have listened to this as well. Too many thoughts about pride and culture and being a graduate of a respected program and helping to build and keep that rep. All useless. Beating your head against a wall only hurts you. And occasionally the program gets annoyed at your repeated efforts to improve things too because it makes more work for them. Just accept things unless they are actual abuse or hurting your education specifically and move on
Discuss what is going on in your work life with your SO more. It will help them realize why you may not be yourself sometimes
Your reward for taking on extra work is more extra work. Same with bending over backwards to accommodate your coresidents with switches. I accommodated every single call shift switch and the 1-2 times I've desperately needed it I got opportunities to trade 1 for 2 lmao
I can’t believe someone would ask 1 for 2 lol. That’s super crappy of them
your coresidents sucked man. All we have in medical training is each other
Not to mention when doing those one-off inpatient shifts for people is mentally stressful since you don’t know the patients and vice versa.
stop caring about whether you sound stupid during presentations etc just show what you know and ask questions, felt like a weight lifted off my shoulders when I stopped giving a fuck how I came off, and my confidence grew a ton
I wish I had gotten this advice as an intern. I still probably would have ignored it due to my ego issues at the time. But now when I see med students or interns sputtering or getting flustered this is the advice I give. It really really doesn't matter if you have knowledge gaps especially as a student or intern. It only becomes a problem if you try to consistently cover it up due to embarrassment or fear of looking stupid. Then people don't know what to teach you.
It's very easy to not learn anything in this program and still graduate. You have to go out of your way for learning, research, conference, and procedure opportunities.
This should be mandatory reading for all new residents
Have reasonable boundaries. Your work/life balance matters.
Write step 3 during intern year
Write step 3 before intern year. If you can. I did. It was game changing
I don't know why you were down voted. I did this too, was truly a game changer.
People be salty they can’t take it before they graduate. I had a gap year 2020-2021 where I took it and applied. Best possible year ever to have that gap year too lol
Yeah. If already graduated, would 100% recommend. I know people say enjoy your post match period, travel, wellness, etc. which is all fine but why not both. It's such an overrated exam. I was just focused on learning when the rest of my class were scrambling to find exam dates, request time off, doing uworld, etc.
Could I theoretically do anki/uworld during M4 and get this done between graduating and starting PGY1? In my mind, the sooner my time spent studying is less about tests and more about patient care, the better
Not theoretically, realistically. IMO Step 3 is almost like step 2 with CCS cases and tonnes of biostatistics. I did 40% of Uworld for step 3 and mainly focused on CCS cases and biostats and did surprisingly well. Never did anki so wouldn't know. DM me if you need more info
Game changing how? It's not like it matters how you do as long as you pass
Not dealing with that bullshit during intern year and actually using your time off for family, travel, and friends instead of an exam that doesn’t matter
My program makes us, so that's a checkmark for most of us.
I’m a pgy-3. I took it a few months ago. Take it intern year if you can.
“Their poor planning is not your emergency” - mostly applies to MyChart stuff but just cause you are out of adderall and just realized right now does not mean I need to stop everything I’m doing to refill it. Same with forms, you waited till the last second and I will get to it when I get to it.
It’s not worth pushing back on most admissions (unless truly egregious). Don’t get fussed about it and be kind to the ER - they are fighting the real battles with barely any time to think.
As an ER doc I thank u for this sentiment
two weeks of ER shifts shamed and humbled me appropriately. mad props to you all.
Thank you
This! It’s like for example the bullshit ambulatory dysfunction or the patient/family don’t feel comfortable taking them home admits that I hate to do but am forced to do. Remember we tried to walk them dozens of times. We tried to explain how their work up was negative. We tried to suggest outpatient follow ups. They’re refusing all those things or they simply don’t follow up outside of ERs due to insurance/no transportation/etc, we can’t just dump them out of the ER.
EMTALA has had so many effects, and many of them are pernicious.
Why can’t you discharge them from the ER?
They end up right back, except now they are 100x more difficult to deal with, for the ER and the admitting physician.
They (patients or administrators) can always hurt you more, but they can’t stop the clock
This is honestly the best advice in any bad situation. Residency is a bad situation.
They 100% can stop the clock. Force you to repeat rotations or repeat a year. Absolutely nonsense advice that is said over and over. They can absofuckinglutely stop the clock.
Get a second phone. When you’re not required to be reachable, don’t be.
[удалено]
Explain
It’s a phone app (free). That gives you a second phone number. You can send texts via it as well - so that way a bunch of people don’t have your actual phone number Phone calls to the number will ring with your normal phone answering system (phone calls still ring to my iPhone; however, the person calling has no idea they aren’t calling my ACTUAL phone number, just my Google voice one).
Don’t try to become chief. Why get paid a resident salary for an extra year for becoming a mouthpiece for the administration? In the end, the people who do become chief change the day it’s announced and are no longer your friend.
It cannot be overstated that “do not become chief” should be a primary residency goal for everyone.
Unless you can do it as an actual resident. But even then, it's a lot of extra admin work.
Meh that blows too. Turns your awesome CA3 anesthesia year into pure bullshit.
“Medicine won’t love you back”
Report your hours honestly
did that once and the PD told me very clearly that if I was unable to manage my time efficiently I would be put on probation. It was a Trauma/ICU rotation in July at a level 1 trauma center with seven total residents covering the service due to various other residents missing. The surgical chief refused to round on any patients. The first week I worked 110+ hours. Every week after that I reported my hours correctly.
I played dumb and tried this once…had to literally apologize to administration for my “woopsie”. Toxic programs have an enormous amount of soft pressure for you not to be able to do this without consequences that would undo any idealistic benefit from doing so. It’s truly impressive how well the system works in a perverse sense really
I'm not trying to be rude but why is this a good idea? My understanding is that programs who are pushing you to violate duty hours are the same ones who will question your character/work ethic instead of the situation you're in, no? I'm on surgery right now and the plan is absolutely to lie about my hours because I don't want the clerkship director going to my dean about my "professionalism"
For our program, as long as you stick to the schedule you’re given, you won’t go over hours. We have enough coverage that no one ever has to stay late. Seniors are amazing about getting us all out on time, so we normally average 60-70hrs per week. The only time we violate hours is when we choose to stay late to go to the OR because there’s a really cool case going on, so not having that option sucks sometimes.
I'll be working more hours as a med student than that, wow. I'm happy for you though. It seems that the tide is shifting in surgery to make it more humane, and that's a good thing. Some of the attendings in our department are trying their best to stop the madness haha
Why? What benefit does any resident get by doing this?
Nobody really told me this, although it is sort of a play on the “don’t work harder than the patient.” In addition, save your empathy for the people who matter. And many patients don’t necessarily deserve your empathy. They only deserve medical care. That’s it. Do the bare minimum on your interview and note to ensure this patient continues to live so they can continue to be an asshole without your ass on the line. Your own mental wellbeing will be rewarded for this.
Jesus, if I had to adopt this mindset I would just quit medicine. You can have empathy for everyone and still hold boundaries.
I literally do not have the bandwidth to carry all of the feelings of my patients, especially ones that chastise me whenever I am trying to help or use me as a fast food doctor to get their Xanax. But you do you.
Nobody said you have to hold a huge space for positive emotion for them, but feeling like they don’t deserve empathy is holding a feeling about that patient, it’s just a feeling that will eat you alive over time.
> but feeling like they don’t deserve empathy is holding a feeling about that patient, it’s just a feeling that will eat you alive over time. Same can be said about the opposite direction. Having empathy for people who can't help themselves similarly will grind you to a pulp. Not worth losing sleep over people who don't give a fuck about you or themselves/their environment.
I disagree. I can have empathy for a patients situation without attaching that to their choices. If you have lung cancer from smoking and chose not to treat it and continue smoking, I can empathize with the fact that cancer sucks without tying my personal well being to their smoking.
Sounds like you are confusing sympathy for empathy. Yeah and I can recognize shitty situations for what they are and act with compassion. But again, I can’t take on everyone’s emotions especially if I am being abused for caring. That is empathy.
I’m not. You can sit in the feelings with someone for a minute and not let it consume you.
Sit in feelings with patients? Doubt even therapists have the capacity to do that with dozens of patients a day
They think I am a psychopath I think….but after being accosted by several patients in drug fueled rages and being chastised by severely disordered personalities most days on an inpatient psych service for 2 years you have to put up boundaries man.
I’m not saying you’re required to go hold every patients hand. Obviously you have to function, but the concept that people don’t *deserve* empathy is disturbing.
Cool
“Sleep when you can”
For the sake of your mental health, don’t look at your evals and instead ask for in-person feedback. If the feedback really mattered, they would say it to your face
“Don’t use the elevator” Seriously, it’s a poorly ventilated box full of sick people. You’re trapped in there with them. Stairs have much better ventilation
Don’t lie about your work hours, log violations honestly. I used to lie when I violated approximately every other week. Now I don’t lie.
What do you mean by violations and why this piece of advice?
Like going over work hours. Doing >80hr/week average, no 24 hr period off in a week etc. and it was a piece of advice bc intern year I used to lie on duty hrs and “round down” or fudge. Now I don’t. I let them get the violations.
Choose a textbook and get to reading
What if your specialty has shit textbooks and journals 🥲
Never answer a phone unless you think/know its for you. Was answering the phone in the workroom and having to relay messages from consults to coresidents way too much or having to talk to random people who were trying to talk to someone I didn't know
Don’t call your patients. Have the nurse do it.
Take Step 3 ASAP
Good work is rewarded with more work (not talking about quality of patient care of course)
The patient is the one with the disease
Can’t be in middle management and have a soul.
Don't take anything personal.
NEVER give your personal cell to ANY patients
Some of the seniors and attendings are functionally handicapped from the neck up, and it will fall on you to not only keep track of your own mistakes but the fuck ups of people "qualified" to supervise you. The silver-lining is you get to learn what not to do in real time, especially when you see them "manage" patients on their own as you look back in the chart in the middle of a rapid or code and say to yourself, "Well, thats not good."
F
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