Dear Incoming Interns,
Congratulations on matching and reaching the end of medical school! I am sure you are very excited to be graduating, and we interns are equally excited for you as it means we are about ready to say “so long” to our intern year. (Right now, I have 62 clinical days left – but who’s counting?) Intern year is one steep learning curve after another. Just about the time you figure out a particular service, you switch to the next. Over time, however, themes emerge, the transitions become easier, and the mass of random lab values, medications, signs and symptoms, slowly gel into cohesive patient narratives. Below is some of my own hard-earned advice from this year, some practical, some personal.
– Take the time to get to know your nurses. Nurses have some of the most difficult jobs in healthcare, carrying out those orders you put into the computers while constantly monitoring and responding to the needs of the patient. Often, they have years of experience and have seen many, many July interns – the good, the bad and the ugly. You want to be one of the good. Start by checking in with your patients’ nurses. Yes, it can seem like a pain, like an extra few minutes you don’t have, but I’ve found that you save time in the long run (a quick face-to-face can save countless pages) and have better patient care. Also, when in doubt, nurses often know the answer. On call overnight and feeling very much on my own with a list of about 70 patients, the nurses were often the first people I turned to. Simply asking, “So, what do we normally do?” can set you down the right track. Listen to their suggestions; even if you don’t end up following their ideas, everyone appreciates having their suggestion heard. However, if they think someone is sick and want you do go and see them, go. If they feel like someone is not appropriate for the floor, they likely have a good reason. I’ve also found that I get much farther if I explain my reasoning. You learn quickly that if you want to ensure something is done, verbal communication goes a long way. To this, I’ve started adding my reasoning. While early in the year, I might have just called the nurse and said, “Can I get an EKG on Ms. Smith?” I find I get father and establish better rapport if I give my reason. “Can I get an EKG on Ms. Smith because her QTc was a little long when she came in and just started her on Haldol?” Just like you appreciate to know the reasoning behind your attending’s random requests, your nurses will appreciate it.
– Consider the MSU. In academic research, there is the concept of the MPU, or “minimum publishable unit,” which is essentially the smallest research project one can get published. When tenure often replies in part of the number of papers, this idea can be critical. As an intern, you become skilled at creating the “Minimum Signable Unit,” the note that conveys what needs to be communicated with the least extra verbiage. Gone are the days of spending hours on your notes – I remember, as a second year med student, taking over ten hours to write a note an admit note about a psych patient for one of my courses. Even as an MS3, with at most four patients, a grade depending at least in part on my thoughtful assessment (or so I told myself – I’m fairly sure 99% of my notes were never read), and not a whole lot else to do with my time, a significant portion of my day could be consumed by notes. Now, more than twice the number of patient, orders to place, consults to call, medical students to organize, and the desire to leave the hospital at a decent hour, notes have become streamlined. Update, sign and move on.
– Ask the patient. He knows his story far better than any chart. I don’t know how many times heavy chart review can be avoided by simply traipsing back down to the ED and asking the patient you are in the process of admitting. Or send the med student. As an intern, you can do that.
– You won’t be the first to:
feel completely overwhelmed;
have a meltdown in the bathroom;
explain your red eyes are due to allergies rather than emotion.
You will encounter a lot during intern year – both tragedy and triumph, but sometimes particularly heavy on the tragedy. Often, we don’t talk about these things – that unsuccessful code blue we ran to disrupted our day’s workflow, after all, and now we are behind. So it’s back to work as usual. It can be isolating. I knew, after all, that this would be “part of the job” so I didn’t want it to affect me. Often, I held things together in the moment, numbed by the intensity of the event and still needing to care for the rest of my patients. I think there was part of me that assumed everyone was handling this better than I, that they weren’t affected. We were all putting on our game faces, fooling ourselves so as to fool the rest of the world. Keeping things to myself, the tragedies added up, until I developed the belief that I had been having an inordinately traumatic intern year. Until I decided to start talking about it with my co-interns. Turns out my experience has not been unique, but rather universal. Recognize that this will happen to you. Work on finding a (relatively) healthy way to deal with it. For me, it’s been some combination of talking to my co-residents and finding outlets on rough days.
– Admit when you don’t know the answer, and then give yourself a break. You are learning a lot. You will not know everything. If you are asked something and don’t know the answer say so. The same goes whether you checked something if you did not. Despite your absolute best efforts, you will make mistakes. We all do. As an intern, you are expected to learn from them and, hopefully, not make them again (making a new mistake, however, is totally par for the course). Remember that Swiss Cheese model of protecting the patient from medical mistakes? That’s why it’s there. Now, don’t get me wrong – due diligence is absolutely critical to being an intern. You should be scared to make a mistake. A certain level of obsessive compulsive perfectionism is good for patient safety. But don’t perseverate over your mistakes – there isn’t time. We all have feelings of being utterly incompetent this year (probably as R2s as well, but I can’t speak to that yet). However, at some point in the year, a rather amazing thing happens. Your attending will ask, “So, what do you want to do about Mr. Smith?” and, rather than looking desperately at your senior hoping they will pipe up with an answer, you actually know what you want to do. Your attending will nod and move on like nothing even happened, but you will float around on a little cloud – until the next question.
Welcome to intern year, doctor.
Dear Incoming Interns,