Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Resident responsibility at a Level 1 trauma center

Colin Son, MD
Education
June 23, 2011
90 Shares
Share
Tweet
Share

Debates over resident autonomy are nothing new. Informed patients are sometimes reasonably concerned about just how much responsibility for their care will be delegated to their doctor’s trainees. Care within academic medicine, especially acute inpatient care in a public system, can and does sometimes mean going a whole admission without meeting the attending physician presumably responsible for your care as a patient. At least in my limited experience. This as a fact even as we progress towards more resident supervision.

The quality of care teaching institutions and residents provide versus community care is a mixed bag by the literature. You may be aware of the dreaded July effect.

There is a unique example of this at some major trauma centers. In most Level I trauma centers the surgical subspecialty services are, at least documented as being, readily available but not necessarily the attending surgeon him or herself. I think it is reasonable to say that, of the surgical subspecialties, neurosurgery sees a level of acuity that other surgical subspecialties simply do not deal with.

Yes, that open femur fracture is an emergency for the orthopedic surgeon but not quite of the same nature as that massive epidural hematoma.


A coronal recon of an epidural … that’s not good

A Level I trauma center has, at a minimum, an upper level general surgery resident in their fifth year of training, and more likely an attending trauma surgeon, triaging all the trauma that comes in. But as a surgical subspecialty often the first “neurosurgeon” to see a patient suffering serious neurotrauma is a lower level neurosurgery resident. A not unlikely scenario is an intern, a neurosurgeon in training who less than a year ago was still in medical school, who serves as a conduit between the patient with the head or spine injury and the attending neurosurgeon or between the patient and an upper level neurosurgery resident who then communicates with the attending neurosurgeon.

And therein lies the uniqueness.

An attending trauma surgeon is standing at bedside as a patient with an peritoneal visceral injury needing an exploratory laparotomy and he makes that determination right there without any filter. But to operate on a subdural hemorrhage is informed by what a junior neurosurgical resident reports.

Consider this report:

Hey chief, sorry to wake you, I’ve got an 88 year old man who presented status post a fall from his wheelchair at his nursing home five hours ago. He’s got a large right sided subdural. I’m measuring it now and it’s about a centimeter and a half and he’s got nearly two centimeters of shift. His basilar cisterns are already gone. Per report his right pupil was fixed and dilated at the scene. He’s an hour out from intubation and paralytic and sedation and he’s GCS 3T and he’s 5 millimeters on right and non-reactive and 3 millimeters on the left and sluggish and I’m not getting any corneals or cough.

Versus:

Hey chief, sorry to wake you, there’s an 88 year old man with a right sided subdural status post a ground level fall. He’s got pretty significant shift. He got succ when EMS intubated him and I’m not sure if it’s worn off or not. Right now he’s GCS 3T, he’s anasacoric with his right pupil at 5 millimeters and nonreactive and with his left at 3 millimeters. I don’t get any corneal reflexes but that might be the paralytic. I understand he was pretty independent prior to this. Do you want me to wait and see if the paralytic wears off or just get the operating room moving now?

And that filter the in house resident provides matters I’m convinced.

Now, to be fair, there are checks. If the attending trauma surgeon in house or the upper level general surgery resident doesn’t agree with a decision made over the phone for or against surgery for a head injury they’re certainly prone to call the attending neurosurgeon. But such is dependent on the natural temperament of the trauma staff and they encounter an attending or an upper level neurosurgery resident at home who has already had his or her opinion informed by what the in house neurosurgery resident has told them.

That’s not to say I’ve ever seen this process lead to what I consider inappropriate patient care but it is certainly a heady responsibility for the in house resident to present the uncolored facts. And it is certainly something to think about when considering the level of resident responsibility, especially with acutely injured patients.

Colin Son is a neurosurgical intern who blogs at Residency Notes.

Submit a guest post and be heard on social media’s leading physician voice.

Prev

Physician consolidation places health reformers in an ironic dilemma

June 23, 2011 Kevin 7
…
Next

Tips to make the most out of your national medical meeting

June 24, 2011 Kevin 0
…

Tagged as: Hospital-Based Medicine, Residency, Specialist

Post navigation

< Previous Post
Physician consolidation places health reformers in an ironic dilemma
Next Post >
Tips to make the most out of your national medical meeting

More by Colin Son, MD

  • A hospital transfer may not always be a good thing

    Colin Son, MD
  • Is drug resistant bacteria a major public health issue?

    Colin Son, MD
  • a desk with keyboard and ipad with the kevinmd logo

    A physician removed from the reality of acute care

    Colin Son, MD

More in Education

  • The pros and cons of taking a gap year during medical school

    Med School Insiders
  • Breaking the silence: the truth about mental health challenges among medical students and why medical schools must take action

    Erin Waldrop
  • Breaking the stigma: Encouraging mental health help-seeking in medical trainees

    Anonymous
  • I’m not so different from Lionel Messi – and neither are you

    Lauren Tien
  • 6 ways ChatGPT can help you succeed in medical school

    Drew Bergman
  • Is it time to say goodbye to medical school rankings?

    James Goldchild
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Unveiling the intricate link between housing costs and health care

      Harvey Castro, MD, MBA | Policy
    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
  • Recent Posts

    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
    • Fixing the system and prioritizing patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From medical student to intern: Discovering a deeper connection with patients

      Johnathan Yao, MD, MPH | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Unveiling the global pandemic threat: insights into risk factors and urgent measures for prevention

      Ton La, Jr., MD, JD | Policy
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 4 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Novel IDH1/2 Inhibitor Shows 'Dramatic Effect' in Low-Grade Glioma
  • Nivolumab-AVD Boosts PFS in Untreated Hodgkin Lymphoma
  • 'You Can't Yoga Your Way Out of This': What We Heard This Week
  • New Standard in Operable EGFR-Positive Lung Cancer
  • New Ovarian Cancer Drug Extends Survival in Resistant Disease

Meeting Coverage

  • Novel IDH1/2 Inhibitor Shows 'Dramatic Effect' in Low-Grade Glioma
  • Nivolumab-AVD Boosts PFS in Untreated Hodgkin Lymphoma
  • New Standard in Operable EGFR-Positive Lung Cancer
  • New Ovarian Cancer Drug Extends Survival in Resistant Disease
  • Neoadjuvant Chemo Flops Versus Upfront Surgery for Resectable Pancreatic Cancer
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Unveiling the intricate link between housing costs and health care

      Harvey Castro, MD, MBA | Policy
    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
  • Past 6 Months

    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
  • Recent Posts

    • Breaking free from restrictive covenants to combat burnout

      Raya E. Kheirbek, MD | Physician
    • Fixing the system and prioritizing patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From medical student to intern: Discovering a deeper connection with patients

      Johnathan Yao, MD, MPH | Physician
    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Unveiling the global pandemic threat: insights into risk factors and urgent measures for prevention

      Ton La, Jr., MD, JD | Policy
    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Resident responsibility at a Level 1 trauma center
4 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...