This is by no means a comprehensive list -- indeed, I've omitted some of the obvious important questions about call schedules and elective time -- and is skewed toward internship and Internal Medicine since that's my experience so far.
1. During floor and ICU months do you find that you can finish all your work within the 80 hour/week limit without sacrificing work quality or patient safety?
The 80 hour per week limit applies to the average time worked over the last 4 weeks, so it's ok to go over 80 hours some weeks. Sometimes it's essential to stay late to ensure that a sick patient gets the right care. Rushing out the door at quitting time without tucking in your patients will make you a less effective intern, promote bad outcomes, and invite the hatred of your co-interns who cover for you when you leave. However, if residents in your favorite program or specialty regularly work more than 80 hours then you'll have to decide whether you're a committed masochist or just like to dabble in pain.
2. What time do interns “like” to get in to pre-round on patients? Do you “like” to pre-write your notes the evening before?
If most interns feel compelled to arrive an hour or more before the standard intern start time then this will almost certainly lead to duty hour violations in the setting of a typical call schedule. You shouldn’t have to spend evenings pre-writing notes or arrive at 5 a.m. to get your job done -- most of the time, anyway. If you find yourself alone in the slow boat then you should ask your upper year residents to help identify ways to become more efficient. If the only way to get out on time is to do more work at home then the program has deeper issues.
3. Does chronic underreporting of duty hours really happen in some programs?
BTW, this is not an appropriate interview day question. Yep, it happens. More in some specialties than others. There’s a lot of work to be done by a set number of residents. Try to avoid programs with a pervasive culture of underreporting duty hours. See my masochist comment in #1. Residents often want to protect their program from being cited by the ACGME for violations. This failure to report gives the program a false sense of how much work is really required of residents. In programs where residents chronically underreport hours, individual residents may fear being singled out as the only resident who can't finish work in a timely manner or worse, as the resident who got the program into trouble.
4. How many interns/residents are on each floor team? What is the maximum number of patients per team? What is maximum number of patients for each intern?
Adequate exposure to a variety of patients and cases is essential to develop competence, but chronically handling too many patients at once makes it tough to develop a deeper understanding of medicine's complexities. How many patients is too many? The ACGME caps interns at 10 patients (down from 12 as of July 2009). The ACGME caps a single-intern team, which includes one resident, at 14 patients.
Realistically, it’s disheartening to care for 10 patients when you have no time to briefly review, say, the workup for hyponatremia in the new edition of your trusty Massachusetts General Hospital Handbook of Internal Medicine. It's fine to learn from attending physicians and residents, but it's also important to fine tune your patient care plans through your own research and study.
Note that you will help to care for your resident’s patients since nurses will automatically page you for all the patients on your team. You will also likely write full chart notes for up to 14 patients on a weekend when standard rounds are not held, so it's a good idea to keep any intern or team caps in mind when you select a program.
5. How do the floor teams split work between interns and residents?
In some programs a team's work is split close to evenly between interns and residents. At the opposite end of the spectrum, an intern may cover all patients on the team up to the 10-patient cap. For the purpose of maintaining intern sanity, an ideal approach is likely somewhere in between. Note that upper year residents take responsibility for the entire team of patients so it doesn't make sense for them to evenly split the progress note burden with an intern. The resident who does this is a saint (and likely a masochist). S/he will warmly hug you at the end of the rotation. Warning: this species of resident is rare.
6. How much do attending physicians teach in this program?
This is essential whether you're a Preliminary intern gaining a year of experience prior to residency or a Categorical intern in it for the long haul. As an intern you'll be a hospital employee with a contractual responsibility to care for patients, but you're also there to gain competence for when the time comes to practice without a residency safety net. Effective teaching that is relevant to your caseload increases the educational value of your hard work. Don't get stuck in a residency program where the work-education balance is anything but.
7. What proportion of the patients on each team belong to "private" attending physicians?
Rounding on a full census of patients takes time, but even brief discussions about a patient add more to both your education and patient care quality than merely carrying out the wishes of a private attending with whom you have little contact. For better or worse, I provide more attentive care to patients with teaching attending physicians since I have regular contact with them throughout the day. In my opinion, no more than 25% of a team’s census should consist of private attending patients, and the less the better.
8. Is lecture time protected, either entirely or from all but urgent/emergent pages?
Protected lecture time means you won't be paged during educational time because "Mr. Smith wants to know when he can go home" when the paging nurse knows perfectly well that Mr. Smith isn’t going anywhere until noon conference is over. Protected or even semi-protected lecture time suggests that the program will pay more than just lip service to educating you.
9. Do interns dictate discharge summaries?
Some programs do not require interns to dictate discharge summaries for patients but assign this important and time-consuming task to upper year residents. Dictating discharge summaries requires you to coherently and succinctly describe a patient’s clinical course and your team’s underlying clinical reasoning.If you dictate from Day 1 you may be a better intern since you will gain a broad view of what could otherwise seem like a bunch of disjointed details. You’ll also have a chance to identify things that were missed to do better next time. However, it is a red flag if interns regularly must dictate discharge summaries from home because they can't find time during the 80 hour work week. Many (most?) of the big university programs do not require interns to dictate discharge summaries. If it's good enough for them, it's probably good enough for you. Go ahead, save yourself a little misery.
10. Can you access electronic medical records from home?
Convenience or a sign of extra obligation? Depending on the program, maybe a little of both.
Overall, you probably won't find the perfect combination of work, education, and leisure in a program but it's fair to seek the right fit for you. If something strikes you as a red flag in a program I urge you to dig deeper rather than just hope for the best.
Don't settle for just any program that will accept you. Unless you're a very weak candidate or interview at only a few programs, you will likely have choices regarding which program will be your constant companion for the next 1-5 years.
As many program directors shared with me last year, the residency match is a buyer's market. You, the candidate, are the buyer and have limited opportunity for returns or exchange. Spend wisely.
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