Every July, freshly-minted doctors begin their first step as healthcare providers with their intern year. Regardless of the specialty, everyone’s intern year provides important learning opportunities that will influence the remainder of their post-graduate training. There are endless resources which focus on how to prepare you for residency interviews, how to identify good residencies that fit you, and how to impress program directors to obtain a residency position. This article covers the next step: how to lay a solid foundation in intern year so that you’ll thrive during residency and become a spectacular attending (your ultimate goal). You’ve gotten that coveted PGY-1 spot. You’re going to be a real doctor with all the responsibilities and, yes of course, the perks. Very few formal steps remain between you and your lifelong career; however the steps which remain are among the most important in terms of personal, professional, and leadership development. In this article, various senior residents and new attendings share their insights on internship, what they recommend, and what they would’ve changed if they can go back.
- Set an Expectation for Yourself
People who have a good experience with residency years know what they want from residency training. These final years are the only ones left where you have autonomy over your education AND also have bountiful resources to pursue whatever you want to learn. Diana, an attending in Dermatology warns, “when you become an attending, you have to provide your own resources unless you work with students or residents. What’s difficult is that you don’t get guidance when you want it and it becomes harder to seek out.” A lot of learning in residency programs is self directed, even if you match into an “academic” program. Majority of senior residents with whom I’ve spoken recommend compiling a list of things you want to learn. That list should include everything from diseases you want to see/treat, procedures you want to do, and any logistical things which schools do not teach and boards do not test, such as insurance coding to medical staff administrative duties if you plan on becoming a hospitalist.
Jason, an internal medicine 2nd year resident, made a list for himself after his intern year. He wanted to make sure he performed enough procedures and saw enough ICU cases so he could better prepare for critical care fellowship. “In retrospect, I should’ve been more diligent about it during my intern year. Now that I am leading a team, I give my intern priority when it comes to procedure and I am little more hands off. Your intern year is absolutely the best year to learn because everyone is focusing on teaching you.”
Further up the hierarchy, many attendings with whom I have spoken express concern about whether residents are receiving enough training in terms of breadth. As a resident, you may see and treat more of a certain pathology (say for example, CHF or COPD) and not the entire spectrum of things within your ability and scope. A lot of things affect the spectrum of illnesses you see (demographic, socio-economics, capabilities of your hospital, availability of consulting doctors, etc). Creating an expectation for yourself to identify these gaps ensures that you receive as much breadth to your training as possible.
- Read on Every Aspect of Your Patient’s Care
Reading is difficult to do in residency with the limited time and energy you have. However, nothing is more essential to your development as a doctor. Your patient encounters are opportunities to identify weak spots in your knowledge of patient care. Points where you’ll commonly find weak spots include: when asked by nursing for treatment direction, family conferences/meetings, coding, and patient education among others. Whenever you identify something you don’t know, you should add it to your reading list.
“A good goal is to knock off 4-5 items on your reading list per day with spending no more than 45 minutes total,” advises David, a chief family medicine resident. Even “mundane” patient presentations carry educational opportunity. “As an intern, I treated CHF patients every week,” according to Family Medicine 3rd year resident, Sam. “But every patient was a different enough where it became clinically significant. Different comorbidities, complicated adverse medication reactions, allergy profiles, all contributed to new challenges in patient care and became topics worth reading.”
Reading through cases allows you to widen the set of clinical tools you’ll have at your disposal once you become an attending. As patients become more demanding of their care providers, your ability to tailor your patient care will contribute to your success as a physician. As you dive deeper into your medical education, you’ll find that you can expand on any case for your learning opportunity.
- Take on as many patients as you can
As someone who supervises interns and residents now, I’m very concerned when I hear interns tell me they aren’t following a patient because they’re not assigned to that case. Most attendings will understand that interns feel overwhelmed and we likely won’t mark you down if you tell us this. But each case is a chance to learn how to take care of someone, and you will begin to see how management will differ when you cross cover another team or if you are ever asked to chart review. While in intern year, I’d advise you to follow as many patients as you can. Chart review is a great tool for learning. If it’s not your patient, you’re not responsible for notes, care decisions, rounds etc; therefore, these cases should be low pressure opportunities to learn medicine and management.
Andrew, PGY-2 in family medicine, recommends following management on as many teaching cases as possible. “I used to read up on cases that were followed by other teaching teams. They supplemented my own cases and it was a really good way to learn how other teams manage different presentations. Furthermore, it helps you to prepare for cross covering and moonlighting opportunities where you care for patients who are already being worked on before you got involved.”
Alice, a 3rd year PMR resident further adds, “Cases that I cover for other teams I add to my list of patients for whom I participated in care decisions. The more patients you follow, the more impressive of a candidate you’ll be to employers and fellowship directors.” Making yourself a stronger doctor should be your primary goal during your training and beyond.
- Learn the other jobs of being a doctor
Note the plural to the word, “jobs.” There are many duties of a physician beyond bedside care. The majority of these duties were not taught to you in medical school and some aren’t even taught to you in residency, at least not formally. Chances are, you won’t be asked to perform these duties as an intern, but be ready to tackle them if you want to be a successful senior resident, chief resident and eventually an attending. As such, getting yourself exposed to these duties as an intern when there are fewer expectations will prepare you for these future tasks.
“Perhaps one of the more important extra duties we perform is clinical patient advocate,” says Jenny, a family medicine hospitalist. “ Every hospital has advocates and customer service, but doctors have the responsibility of being clinical advocates and since we lead direction of care, it’s vitally important we remain our patient’s advocate. Physician-patient partnerships like these will improve overall outcome of care, especially in the outpatient setting where doctors work largely by themselves.”
Related to being patient advocates, many doctors take on additional role as case managers. “As a resident, I was heavily involved in case management for my patients,” recalls Josh, recently graduated internal medicine primary care physician. “Your goal as a doctor is to return your patient to health and home as quickly as possible. Making sure your patients actually receive their medications to go home with, assisting in their placement in nursing homes if necessary, and communicating with their primary doctor (if you’re caring for them in the hospital) all play a role in getting your patient back health. This wasn’t taught to you in school because it isn’t medical science, but it does impact patient care.”
- Develop good working relationships with all your staff
Residency is difficult. You will need all the support you can get from those around you. Many residency programs promote good working dynamics among the residents themselves. However, the most commonly overlooked source of support comes from ancillary and support staff. During my residency, I found significant encouragement and mental support from staff such as techs, nurses, and even non-clinical staff such as janitors. They helped me counteract burnout much more than my own program and co-residents. They create a larger sense of belonging than my fellow doctors could do, just because there are many more support staffs than doctors. Oftentimes, a friendly “hello” or smile can counteract stress, feelings of depression, and the possible desire to quit which I felt personally on several occasions. Your non-resident co-workers are actually better buffers from burnout than your fellow doctors. Generally, residents tend to dwell on medical issues and even during “off” times will continue to talk about patients and cases. Even if just to blow off steam, this doesn’t help you find balance between clinical and non-clinical things. Other workers can balance your conversations and interactions, adding more things outside the realm of medicine. Some of the more meaningful interactions you will have are likely going to be with support staff as well. As doctors, we tend to be very stoic and we don’t share much of ourselves to others, especially if we think it makes us look weak. Other staff members have shared with me their real struggles, their concerns, and their best moments. I had a large impact in their lives and they had a large impact on mine. These people supported me in ways I could not have imagined and they are integral in patient care as well since they are the first and last to interact with patients and they spend more time with particular patients than any doctor could.
- This is where you wanted to be.
This seems like a silly reminder. However, many of us forget that we wanted and actively pursued this path. Make no mistake, it is absolutely a wonderful place to be. It is your chance to cultivate more than a job. Some may describe it as a calling. I like to think of it as an identity. However, it won’t fall on your lap. You have to make it what you want it to be. Many students go into intern year expecting to be told what to do all the time. After all, it’s only natural; as a student, you’re used to taking instruction. No one really prepared you to make the transition from taking instruction to being self-directed and then eventually to giving instruction to others. I have found that those who make this transition early in their intern year will usually have a very good experience later on in the rest of their residency. The transition is mainly psychological; the actual skills required to be a self-directed leader can be learned over time. You must make yourself ready psychologically for this transition or it would be rather hard to come by itself. Setting this as an expectation early on in intern year will help you become an impressive resident and develop your independence as a practicing physician.
Becoming a physician carries tremendous responsibility, but it is deeply rewarding, exciting, and even fun when you put yourself into your new identity wholeheartedly. Make no mistake, this is not a job; jobs do not carry this level of responsibility. This is a commitment to taking care of living people and safeguarding the length and quality of their lives to the best of your ability and to the wishes of your patient at all times. Laying a strong foundation during your intern year is pivotal to the remainder of your training and development into a solid attending physician.