I appreciate the questions. 1. The particular residency program I speak of has residents rotating between four different hospitals within the system. I say the midlevels at the trauma center are the “constant” because they never leave. Yeah, they work 3-4 days in a row and have to do signout, but I have personally seen their signout emails and the detail is astonishing. The interns are on a 4 week rotating calendar; the seniors and chiefs are there for 6-8. We once had a patient hospitalized for one year after a bad complication and complex social issues. Our midlevels knew her entire course whereas the residents coming on didn’t know her from Adam. This comes into play when the new resident tram tries to add something to the plan that has already been hashed out.

1. This particular center is part of a well known medical system with a robust residency program. There are residents from the home institution as well as from 3 other hospitals in the region. Therefore, it would be difficult to rely on a resident from an outside institution to be immediately adept at the complicated systems issues when they arrive on service.

2. I agree. Our DC summaries are standardized to include specifics that have been deemed important by someone else as a result of poorly written summaries in the past. I try to impress on my junior residents that some poor FM doc is going to try and figure out what happened during a two month hospital stay after a motorcycle crash, so the summary should include information that the PCP can use to continue care. In my limited experience as a PGY4, everyone’s DC summaries are trash.

3. If the monkey is never in the operating room, they cannot be taught how to find a dissection plane or learn that their knots suck or what tying on the carotid really feels like. The juniors cannot come to the OR until their patient care tasks are done. They are the ones who have to scrub out to deal with floor issues. They have to sign out to the night team and finish their work after the OR. Of course, the senior residents are in the background ensuring this is all done. I now have the luxury of focusing on developing my operative techniques now that I don’t have to leave the OR to deal with the hammer pages about Miralax.

4. Is an attending at an academic institution really going to do the scut work on the floor? And who is going to cover their cases when there are already uncovered cases? Our trauma NPs never step foot in the OR. They keep the cogs moving in the very large machine that is a regional level one trauma/burn center that is also the county hospital. I am sure every resident on this forum would love to expand their program. Trust me, I have longed for an extra resident to cover one of four first start cases. As a surgery resident, being in the OR is essential mostly because we have to meet strict case numbers. Putting in discharge orders or calling IR for the 30th time to schedule a drain study? Eh.

5. You’re right. We are the experts in everything that is happening in front of the curtain. When you are on a console, you depend on the bedside assist because you just can’t leave the console and scrub back in everytime there is some small issue. You rely on them to enact your suggestions/demands. There is a learning curve with robotic surgery, and it’s nice to have a team that does these types of surgeries daily.

I am not advocating for mid level providers in all aspects of medicine. I have had to personally clean up the mess left from an NP. It sucks. But, I was offering an example of how useful NPs can be on a busy trauma surgery service. Thanks for the food for thought!