Things I wish I knew as a PGY-1...

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1. work hard, be honest with yourself

2. take the good advice, take the poor advice out with the garbage

3. don't even think about trying to chase your evaluations. If they are legit take their advice. You'll see a trend. The good, happy with their own life attendings are usually the most honest, and will tell you when you've done good, will try to inspire your confidence. The unhappy, passive-aggressive attendings will try to make you feel like crap, all the time, no matter how hard you worked. Blow them off, completely. Or laugh at them....it's your career...remember you are under a contractual agreement with your program...you have certain obligations to fulfill, just as the program does. And they can't fire you without legit causes... Heard horror stories before???? who hasn't, ask around and you'll find for every supposed horror story you'll find a practicing physician who stood up for themselves, played the game, kept the dirt they witnessed, and used it if push came to shove. These people have more respect than any two bit underpaid attending or PD ever will

4. oh...and don't forget quietly to record every event and person who does something wrong...wrong med, attending doesn't return pages, etc....this might come in handy later. Everyone is out for themselves...Your an adult now, and yes this is how the world works. Don't believe me..go ahead pretend it's not like this and you are going to get screwed some day.

Good thread. I will echo some of the above:

1. BE ORGANIZED. If your census is small I would do an index card for each pt, on one side list their issues/meds/to-do's, on the other side list daily labs. That way you don't have to bother copying your notes and carrying a bunch of paper around. If you are on a surgery service write stuff on your list in a systematic manner (see #2).

2. Corollary to #1: USE A 4-COLOR PEN. I write To-do's in red, labs in blue, etc. It's my best friend!

BE CAREFUL DOSING MEDS with the ELDERLY. I had a crosscover intern give a little old lady 1mg of dilaudid, e.g.

Ask questions to the consultants. Often they are eager to teach esp at a university.

Everyday, read about one thing on one patient.

Everyday, do something important OUTSIDE MEDICINE.

For the soul: remember this is more than just a job, more than just getting things done. Try to minimize the cynicism.

The intern I worked with got paged at least once every call night to read an x-ray to tell if a line/tube was placed correctly.
I looked up this guide for her:
http://www.radiology.uiowa.edu/Radsh...tes/Mullan.htm

It tells you what to look for to ensure proper placement of each device.
I hope that is helpful to someone else, too.

Good link!

Cool tips!

Legible handwriting goes a long way...

Originally Posted by tibor75

1. Don't argue w/ nurses, unless it's patient care that's involved. They are not worth it. It's like arguing with a 7 year old. You have better things to do, and talking to a nurse just drains about 10 brain cells per minute.
.

i agree.. its a waste of time.. and dont teach them anything either. because there is no point. They dont have the backround to apply what you just taught them. all they know is flowsheets and writing doctors up.

I wish I knew how to pretend that days of internal medicine weren't about as pleasant as a dull knife under the fingernails, etc. My feelings tend to show up on my face from time to time and the misery of doing an IM internship was obvious. It didn't do me any good to accidentally let coworkers and superiors see my displeasure, so I should have hid it better. Most everyone non-categorical will hate medicine internship and my advice is this: hide it!

Originally Posted by johankriek

i agree.. its a waste of time.. and dont teach them anything either. because there is no point. They dont have the backround to apply what you just taught them. all they know is flowsheets and writing doctors up.

Well, that's not very nice. I guess you are just blowing off steam? Obviously there are good nurses and bad nurses, just like any other profession. But treating any of them with a condescending attitude won't help anything. I frequently am disappointed by the total lack of courtesy that the student physician members seem to have for the hospital staff they encounter. Everyone, including the custodial staff, deserves our respect and kindness. Remember that you can have stellar boards scores, but if you can't relate well to other people, you won't be a good physician.

When writing admission orders, ask the nursing staff or unit secretary if they have pre-written orders. Checking boxes is a lot easier than writing everything out, and it provides a guideline to make sure you haven't missed anything. At my hospital, there are pre-written orders for general admission, surgical admission, insulin drip, sliding scale insulin, potassium protocol, and on and on.

Buy moderate or firm compression stockings, as many pairs as you can afford.

I thought as the new PGY1s start this summer, I should bump this lovely thread

here is my tip:
After a Whipple's, make sure you keep an eye out for bile in drain one and send samples from drain two to the lab for amylase analysis...the surgeon will love you long time.


cheers

(I trained back when 32+ hrs straight in-house was still OK. We often had little time for meals...)

When I was an intern (gen rotating program), the residents taught us how to time discharges so that the patient's meal tray would still arrive. We all carried utensils in our lab coats, and we'd pull the curtain and gather around the meal tray, scarfing it down like wolves! It was just a survival tactic, but looking back on it, it's a pretty funny memory. Surgery had every other night on-call, so they were all very thin

We had one talented intern who used an extra-long clipboard. This was so they could tuck their chin, hide their face with the clipboard, prop against the wall flamingo-style (one foot on the wall / knee bent), and fall asleep on rounds while standing up. This intern had an incredible talent for springing to life if pimped during these little naps...they could still answer questions pretty well even when half-asleep.

On a vascular case, lasting about 8 hrs, another intern fell asleep while holding a retractor. The surgeon woke him up by whacking him on the hand with an instrument, but took it in stride...I think he was used to his help dozing off on him, under those work conditions.

I think what helped get us through the most, was we respected the leadership. It was an AF hospital, and our hospital commander later became Surgeon Gen of the AF (Roadman...we called him the Road Warrior). He would appear at 3 AM in the ER sometimes, just to see how things were going. We loved that guy, and our loyalty to him helped to keep us working as hard as we could.

I can't say enough about being extremely nice to the nurses.

I am only two months into intern year and after being very nice and respectful to the nurses (which is how I was raised, so it isn't really out of the norm for me), they are already "batching calls" so that I usually receive 2-3 at a time from a nurses station at night. This makes life SO much easier and decreases the running around that you have to do at night on cross-cover.

Keep in mind, that most (not all) of the nurses talk and gossip with each other, so you can use this for your betterment or to your detriment. Good luck.

Originally Posted by CyberKnife19

I can't say enough about being extremely nice to the nurses.

I am only two months into intern year and after being very nice and respectful to the nurses (which is how I was raised, so it isn't really out of the norm for me), they are already "batching calls" so that I usually receive 2-3 at a time from a nurses station at night. This makes life SO much easier and decreases the running around that you have to do at night on cross-cover.

Keep in mind, that most (not all) of the nurses talk and gossip with each other, so you can use this for your betterment or to your detriment. Good luck.

I have also seen this backfire...interns who are TOO nice and cozy with the nurses, then the nurses feel comfortable paging them with anything and everything since everyone is "buddies"

bump for us starting in June. Moar advice plz.

Be nice with nurses but set boundaries, just like we would with patients. After a few calls I finally started giving my, "Wants vs Needs" lecture to nursing staff on overnight call. Patient has insomnia and can't sleep? Ok, fine. Patient can't take a dump at 2AM or you notice something missing from their med list at 1AM that they won't take until 10AM? Don't give a ****. Save that **** for the day team.

Set these boundaries and once word gets around, your page volume from the wards will drop at least 40%

In a military program, most of the floor nurses doing the grunt work are fresh out of nursing school. They rotate out a lot, so we're constantly getting new RNs. It's a bit of work up front but set your boundaries and take time to educate them on medical stuff and they will not only like and appreciate you, but be better informed on what's important and what is not. Some of them working nights who have been in the hospital for only 5 hours may not realize you're working on hour 22.

* When ordering diagnostic studies, think in decision trees, and always think 2-3 steps ahead. Let's say you order a chest X-ray in someone with a chronic cough. If it's abnormal, what will be your next step? If it's normal, what will be your next step? Write that down in the chart/progress note - so that people who cover for you or see the patient at their next office visit will know what your thought process was.

* When giving bad news to patients, always be prepared to give them what the next steps are. Don't even pick up the phone or walk into the room if you are not sure of what you are going to advise them is the next step. Is the next step more imaging? A biopsy? An ex lap? A referral? What should they anticipate doing next?

* Finally, when preparing to give bad news to patients, MAKE SURE THAT YOU HAVE YOUR FACTS STRAIGHT. I saw a surgical PGY-3 tell a patient (and the family) that the patient had cancer. This surgery resident based this off of his amateur read of the patient's CT. It was very embarrassing for him to have to go into the room later, with the GI attending AND the surgery attending, and tell the family that, actually, they couldn't tell if it was cancer or not. (It wasn't cancer, by the way.) The family was extremely angry and really yelled at him, something that could have been avoided if he had not jumped the gun and rushed to the conclusion that it was cancer.

Originally Posted by smq123

* When ordering diagnostic studies, think in decision trees, and always think 2-3 steps ahead. Let's say you order a chest X-ray in someone with a chronic cough. If it's abnormal, what will be your next step? If it's normal, what will be your next step? Write that down in the chart/progress note - so that people who cover for you or see the patient at their next office visit will know what your thought process was.

That's great advice - I should do that more often in my progress notes!

Originally Posted by souljah1

1. Show respect and gain respect - This will serve you very well when interacting with all health care professionals. Having a genuine interest and learning the names of the nurses, physical therapists, dietitians, pharmacologists, etc will benefit you greatly when you need their assistance. It benefits you in ways you'd never know b/c others wind up going the extra distance for you i.e. IV placement, transport, seeing someone first thing in the a.m. for you, etc.

2. Don't try and cover your ass with a bunch of PRN orders - I have seen lots of errors committed because of this. Yes, PRN bowel regimen on the patient with standing pain meds makes sense. No, PRN tylenol for fever in anyone who you are anticipating an infectious w/u in does not. You PRN orders should be based on the individualized plan for your patient. I had a crosscover intern order restoril 30mg on my ESLD patient who had insomnia b/c of hepatic encephalopathy just so she wouldn't get called at night. She looked like an idiot on rounds. When thinking of PRNs - consider bowel regimens for most people bed bound and on pain meds, but I would discourage using PRN ativan, pain medicines, sleeping aids (except maybe trazodone 25mg) or benadryl. Drug companies already get paid too much, why add to their profit margin by prescribing unneeded medicines.

3. Stay on top of your medication list - We have a system that automatically imports our medication list on our computer based sign on into our daily progress notes. Some people don't pay enough attention to keeping their med list up to date - which can really hurt your crosscover and is generally poor form.

4. Think of discharge planning issues early. When considering your plan for your newly admitted patient, you should think about dispo. Will they likely need PT/OT eval while in house? Will they need a PICC line for home abx? Will they need home nursing or wound care? Nothing is worse (for both you or the patient) than resolving their inpatient needs but then having the patient have to stay the weekend b/c you slacked on dispo stuff. Social Workers can be immensely helpful in this regard.

5. Be proactive - Ask your senior resident early on if you can take the lead in rapid response calls or codes. If a patient is crumping, call the resident for assistance but ask the resident if you can assume the lead. Midway through intern year, this can be very helpful and will prepare you for the next stage of training.

6. Read about one thing per day - You don't have to read an hour, but try reading about one topic for 15 minutes per day. Preferably, something related to your patient. UptoDate is great for this sort of thing, but it is also great to make use of review articles. People who just study the Pocket Medicine book are handicapped.

7. When things get tough, seek your friends and family - Internship is a marathon. Aspects of internship can be difficult and your work starts to become your life at times. When a patient dies or when things don't go well, try to remember the bigger picture. It can also help to seek the solace of an aged physician. This doesn't necessarily have to be in person. Jerome Groopman has a great collection of essays on his website that always help me remember the reasons why I chose this profession.

8. Be a team player - Nothing is more frustrating than getting a crappy sign out from your colleague b/c they "can't wait to get outside and enjoy the nice weather". Your co-interns will really appreciate it when you tuck your patients in.

9. Don't be afraid to pick the brains of the attendings consulting on your patient. If you just follow up the consult note, you won't learn that much. If you take part in the discussion of the consult service rounding on your patient you can come away learning a great deal.

10. Don't stop doing what made you happy before internship.

Sleeping 9 hours per day, going out 3-4 nights a week, working on my tan, and chasing women is what made me happy this past year (MS4).
Feasible?

Does anyone have access to a downloaded version of the UCSF Hospitalist handbook? Apparently it's been removed from the website linked above. If so, please PM me. Thanks!

Deserves to be updates!!

Does anyone have access to a downloaded version of the UCSF Hospitalist handbook? Apparently it's been removed from the website linked above. If so, please PM me. Thanks!

I have the same request ... Anyone girls/guys?

Just exactly how much inpatient medicine sucks.


I think I'd rather be dead than do another month of that crap.

UCSF handbook?

Did you even try a Google search?

I did. Keywords "UCSF Hospitalist handbook." It's there.

Hmm .. I tried to google it for sure but failed to find a copy!!!! I will re-try again. thank you very much.

Alright, i just found a copy 2002- isilo version. did you find a newer/pdf version of it?

Originally Posted by adagio

Alright, i just found a copy 2002- isilo version. did you find a newer/pdf version of it?

It's a really great book. Only place I know you can get it is the UCSF bookstore. Maybe if you called the bookstore you could order one and they'd send it to you? Or have a friend in SF pick it up? They really should distribute it more widely...

Hi Cereal, what toothpaste do you use nice smile

i tried searching online to see if the store has a copy but to no avail. do you happen to have the link?

Cheers

Great stuff

hey everyone,

what was the book someone mentioned---"medicine on call" or something similar to that? Also, does anyone know a good book for more specific management protocols instead of merely mentioning, start spironolactone for ascites.... (like actual doses)

Originally Posted by hidoc

hey everyone,

what was the book someone mentioned---"medicine on call" or something similar to that? Also, does anyone know a good book for more specific management protocols instead of merely mentioning, start spironolactone for ascites.... (like actual doses)

People have mentioned Internal Medicine on Call. I looked it up on Amazon and the newest edition came out in 2005. Is it still relevant or is it outdated? Or are people referring to this newer book called "On Call Principles and Protocols" that was most recently published in 2010?

http://www.amazon.com/On-Call-Princi...3287311&sr=8-2

do a surgery or transitional intern year. the work hour rules make surgery far better than an IM year.

1) Surgery you actually accomplish something other than mentally masturbate until two on rounds every day. By about month three, surgical intern work becomes second nature and you can get all of your work done by about 10 AM on a normal day even with a 20 patient census. Plus surgeons dont care about your notes. You can pretty much shoot from the hip and 90% of your calls are about blood pressure and renewing pain meds. You learn how to get ish done.

2) Medicine is the polar opposite. Every note is raked over with a fine toothed comb, internal medicine PGY 2's and above do absolutely nothing all day if youre even semi competent. Once you figure all this out theres nothing more frustrating than an IM resident whos been looking at car magazines all day finding out you didnt put the extra 2 units of insulin you gaveon the signout then bitching about it after youve done all of the admissions, put in all the h and ps and put in all the orders that day.

3) A good tranny with MINIMAL (less than 2 months) of medicine is probably ideal. More consult months the better.

4) ADCVAANDIML
admission, diagnosis, condition, vitals, allergies, activities, nursing, diet, ivf, meds, labs

Hey look! It's another original post by a surgeon who wants to rant about why they're better than internists. I wish I was a surgeon...you guys are the best!

Haha...Im anesthesia and just giving my two cents on PGY 1 year mang.

Just so I hurt everyones feelings equally, surg prelims have little to no supervision throughout their intern year except by upper level surg residents who learned the same way, leading to an entire generation of physicians who dont have a clue on how to properly diagnose everything and anything properly from renal failure to heart failure to arrhythmias (Id be surprised if 50% of surg prelims could tell the difference between an atrial and a ventricular arrhythmia by the end of their intern year) to all the other crap Ive dealt with all year.

One love.

On a more general note to the whole intent of this thread:
Congrats future interns, you will graduate next month with your MD....psssst here's a little secret you're learn next year...MD doesn't stand for Medical Doctor...it stands for Made-up Degree.

Sure take responsibility, own your patients and manage them to the best of your ability, but don't kid yourself that you're doing little more than playing doctor.

Originally Posted by rachmoninov3

On a more general note to the whole intent of this thread:
Congrats future interns, you will graduate next month with your MD....psssst here's a little secret you're learn next year...MD doesn't stand for Medical Doctor...it stands for Made-up Degree.

Sure take responsibility, own your patients and manage them to the best of your ability, but don't kid yourself that you're doing little more than playing doctor.

What do you mean by that last sentence?

Originally Posted by rachmoninov3

On a more general note to the whole intent of this thread:
Congrats future interns, you will graduate next month with your MD....psssst here's a little secret you're learn next year...MD doesn't stand for Medical Doctor...it stands for Made-up Degree.

Sure take responsibility, own your patients and manage them to the best of your ability, but don't kid yourself that you're doing little more than playing doctor.

I understand what you mean but what a sad little world you must live in. Maybe we should avoid your residency program?

Originally Posted by rachmoninov3

Sure take responsibility, own your patients and manage them to the best of your ability, but don't kid yourself that you're doing little more than playing doctor.

Should have done surgery, then you get to play god!

He means you're called, "doctor" and people (usually not nurses) look to you for wisdom and guidance, but as an intern you really have neither. As a soon-to-be PGY3, I'm amazed at how much I didn't know as an intern, particularly now that I'm able to work with the current interns. Starting PGY2, staff from other services started to treat me with some respect and actually listened to my opinion and recommendations.

Yes, as a PGY 2 former padawans learn how to take naps on the couch until finally, as PGY 3's, IM rezidents have to study for boards all year and learn the Force.

Originally Posted by rachmoninov3

Sure take responsibility, own your patients and manage them to the best of your ability, but don't kid yourself that you're doing little more than playing doctor.

I disagree completely with this attitude. As an intern, you're often there talking to patients, going the extra mile for people, and making critical decisions, often at odd hours when busier attendings, consultants, and seniors would never go so far.

You are a doctor and these are your patients. Do good things for them.

Originally Posted by HooahDOc

He means you're called, "doctor" and people (usually not nurses) look to you for wisdom and guidance, but as an intern you really have neither. As a soon-to-be PGY3, I'm amazed at how much I didn't know as an intern, particularly now that I'm able to work with the current interns. Starting PGY2, staff from other services started to treat me with some respect and actually listened to my opinion and recommendations.

I disagree with this as well. I mean yes you learn as you go, and grow with time. But, if you know your patients well and have a good fundamental knowledge of medicine, people will listen to you and respect your opinions.

Originally Posted by Re3iRtH

Sleeping 9 hours per day, going out 3-4 nights a week, working on my tan, and chasing women is what made me happy this past year (MS4).
Feasible?

If your residency is cush enough, this is as feasible in residency as it is in medical school.

I don't agree with this. As I finish intern year I feel the intern does the most in terms of managing the patient. The length of stay is largely dependent on the day to day decisions made by the intern. (Getting PT, SW involved and making sure tests are done in a timely fashion, removing oxygen and cardiac monitor when not necessary, getting the patient out of bed). It all depends how the patient is presented to the attending as well.

Some good advice here regarding saving time on note-writing: am vs pm, before vs after rounds, etc. I'm going to be starting at a hospital that is completely EMR. Does anyone have experience with how and when to manage time for note-writing (or typing) in such cases?

Originally Posted by shadyhtown

Some good advice here regarding saving time on note-writing: am vs pm, before vs after rounds, etc. I'm going to be starting at a hospital that is completely EMR. Does anyone have experience with how and when to manage time for note-writing (or typing) in such cases?

Do whatever you have to inorder to be safe at first. Doesn't matter how long this takes you. Safety and thoroughness is what is most important. Transitioning to crappy electronic notes will take time, but if given a choice do whatever it takes to be a safe physician. Time management will come later.

As for the made-up degree comment, yeah I wish I could change residencies because there is something very wrong about our internal medicine service. I feel I had more autonomy as a medical student. (yes my PD knows that we all hate the way the medicine service operates and he's trying to change it). Hopefully not every program is like this.
However, a dose of humility to the incoming intern class: for the first 3 months your job description is "show-up and make mistakes". Take all the positivity of graduation with a grain of salt, because soon you will be doctor enough to really mess things up if you are not careful.

I think as an intern you do play a vital role in patient care. This has especially been the case when on a super busy service or while on NF or on a consult month.

Your ability to sink/swim also plays largely on the senior/chief running the service.

Things I've learned:

1. show up early and have a go-getter attitude
2. admit to your mistakes, don't lie, don't throw others under the bus. you'll have folks who may be more social or less social than you, and others may/may not throw you under the bus (and some are quite good that they're very subtle about it but the point is clear)
3. don't whine
4. be a team member. help others. you may need help and it'd be nice to have others helping you.
5. know when to step up and when not to. this is key during rounds. if a senior is answering, don't interrupt. if an intern is answering, don't interrupt. if the attending asks YOU for your input, give your input. don't just go along with what others are saying if you feel it's wrong. you never know, you may be right (or wrong) but it shows you're at least thinking about the patient.

..that the hardest thing I'll ever learn to do is to help a patient die with dignity...

You will come across no-win situations where you're just not going to be able to make everyone (attending/nurses/patient/etc) happy. Sometimes, you're going to get caught in the cross-fire and people are going to complain about you... but if you've done right by your patient and you do this for all your patients, the complaints from the people that just want to be ****ed off at someone and you just happen to be the poor bastard that walked into the room will be seen as such.

(the above can also be rephrased as "welcome to customer service")

UCSF Hospitalist Handbook

I've heard of this book here and there. But the website says it will be available in Spring 2012. Does anyone have an electronic copy of this book.. or possibly the older version?

Hi all! I just graduated IM residency and I am about to begin cardiology fellowship. I have a blog where I usually post tips on health, etc...but my most recent, and favorite post to-date was one on what I learned as a resident. It's somewhat humorous, and very relevant...feel free to share (and please, do!)

www.sizemoreheart.com

Happy reading and GOOD LUCK to you all!!

Dr. Tiffany