First of all, there is no "shining" as an intern. There's just differing levels of pain and humiliation. Create a reasonable goal for yourself, which isn't shining special snowflake, but surviving.
Things you do as PGY1 intern that make attendant's or resident's job easier or more difficult?
is probably my best most organized post on the topic of how to be good
Things you do as PGY1 intern that make attendant's or resident's job easier or more difficult?
I also list how to be baaaad
Comfortable shoes for wards
For shoes, this is "step one" of your success
This goes with my advice, always buy a good bed, and a good pair of shoes, because if you're not in one you're in the other.
Directions out of Burn Out Central?
more on basic self care
Creating rounds list on EPIC?
A *detailed* guide on setting up Epic if that is your system, but can be easily adapted as a system for collecting prerounding data in the am
Stressed out already!
some basic tips, below that is a post on what your job really is
Stressed out already!
same thread, post that is a *detailed* guide on organizing your to-do list and notes that you carry for presenting in your pocket
the pharmacist is your friend, get good at typing and holding a phone to your shoulder at the same time (depending on your system you can bring a plug in headset in your pocket to really go hands free!)
Grave concerns about lack of oversight & teaching at new program
thoughts on approaching the program about problems
Grave concerns about lack of oversight & teaching at new program
more on efficiency, same thread
How does one fail a rotation?
more on efficiency, and asking for feedback, what your job as an intern actually is
I feel like I suck at talking to interviewing pts and eliciting info
taking a faster history, railroading your patients in conversation and smoothing their feathers
What interns should know day 1.
what to know, what to carry, post below the immediate one linked is my
list of useful topics to have a handle on for clinic and wards
What should I have in my white coat pocket as an intern? (books, charts, food, and ect...)
more on what to have with you, custom pockets
Night Float weekend
Some ideas about night float - I recommended the book from the EM Resident Association "Top Clinical Problems in EM" for night float, ICU, & EM rotation
especially as an intern, my first concern was not missing emergencies!
What do you log as work hours?
why you must not only lie about work hours, but how to not get caught in the EHR doing so
Resident friend joked about suicide
Setting up medical care, particularly mental health, for yourself NOW
Alcoholics Anonymous in residency
If you have any substance abuse issues that need looked after. There's also a section in there where I talk about disabilities and how they can mesh with your program (given how common substance abuse and chronic pain our in our cohort I thought it worth adding here)
How to apply for disability accommodations
I wrote this guide for a disabled med student, but the lessons learned here are useful for residents with disabilities as well
Disability Insurance in Residency
definitely think about disability insurance! if it happens to you, you'll likely wish you were dead instead depending how much life insurance for your family you bought unless you bought enough disability insurance
I feel like a hypocrite, but I feel like I'm ready to quit intern year
thoughts about maintaining a professional facade
http://forums.studentdoctor.net/thr...under-anesthesia.1145407/page-2#post-16691284
watch your mouth at all times
Feeling overwhelmed
work place topics to avoid
Unfriendly residency/hospital environment?
my 3 rules for how to get along better ie kiss ass better is buried here
Professional Email Signature format for Residents
Now that you have a nifty title, how should people address you?
Discussing Code Status
End of life chemotherapy: unnecessary, costly, and decreases quality of life
My thoughts on code discussions & setting goals of care...
"annoying" time consuming "chores" shunted to interns in some institutions.... and arguably where you have the *most* impact on patients' sense of well being
How to run a code
not just on running a code but... closed loop communication! that concept will spare you headaches
Tips and Tricks to stay alert on Test Day?
my test tips and tricks.... the ITE matters more than you will be led to believe, and may be helpful for step 3... don't **** those off
Does Zofran cause sedation in your experience?
a few pearls on nausea, anti-nausea meds, anti-emetics, delirium
Be as CYA saavy as
@Law2Doc . He is a shark and just the sort of mindset you will be dealing with and needing to impress in many of your attendings/admin. Everything that
@Perrotfish ever said, just remember almost none of your attendings will be as cool as him. I think
@Doctor4Life1769 gives great advice especially on politics.
@aProgDirector gives great level advice but I wouldn't go in expecting your PD to be as reasonable as they are. Check out their past posts on stuff to learn more about how things work.
My personal mantra, is that your job is to be safe, fast, and pleasant, in that order. Also, you are a notemonkey making love to a pager. Keep your head down and don't make waves.
As I say in my posts above, get as much admin crap out of the way before you start, learn your EHR if you can, gather resources to make your life easier (white coat pocket cards, USEFUL review books, and phone apps), and as others said, live as close to the hospital as you can, get all your affairs settled (dental work, car repairs, new tires, rental car benefit on your auto insurance, disability insurance, preventative care, IUD, dry cleaning, moving, and finding all the stuff you need in your new town like a new doc, drycleaner's, auto mechanic, etc) because you won't have time later.
1) Self care.
If you can, work on getting better sleep. It is the foundation of your day, efficiency, learning, retention, communication.
Where I write about self-care I have tips for sleep. You can also search my post history on that. Not medical advice, but a statement of fact, some people find melatonin to help. It's helpful to know the pattern of dysfunction in your sleep for addressing it. However things like blocking out light, when you last have caffeine, not having any alcohol, can affect quality for the sleep you *are* getting. Maximize your sleep and its quality.
Be sure you are taking the time and seeing to it you have access to good food and water. Gotta keep the machine fueled and oiled. Don't underestimate what fatigue and not enough food and water can do to your brain function.
2) Organization.
I hope that you have Epic, because my detailed posts on that might help you. You come in early - do you have a good system for speedy pre-rounding and taking down that data in the AM?
Do you have a system for efficient rounding on patients to ensure you're on time with that? Somewhere in my post history I discuss how I used a timer on my phone to be sure to have time to not only see the pts, but hopefully go over with my senior so I looked less idiotic.
Do you keep a good well-organized to do list? Are you helping to keep track of the little things? Even if you're not coming up with great plans, being on top of things like start/stop courses of things like abx can really help your team. Same with f/u of cx, img, consult results and the like. Keeping track of requirements towards d/c - what forms/assessments SNFs want, making SW aware, checkboxing on your to-dos those requirements, plus other things like are they ambulating, PO, etc. These are little annoying details.
For abx, I had the Sanford guide. Aside from the hospital biogram, that really helped me to come up with solid plans for my uppers, and made it easy to put in my note how long a course, so the start/stop date too.
Basically to start, you want to be helping to micromanage all the data even if you're not putting it all together. And taking care of scut. Freeing up your uppers in this way makes you less of a bother.
3) History
Somewhere I discuss taking a history in a systematic fashion that can help you not to miss data you should be collecting from patients. It helps if you start to develop and think about, based on a given CC, what specific ROS should you be asking? For example CP should prompt 3 questions always: quality, radiation, SOB on exertion. GI issues you should always ask about n/v, bowel movements, blood in any of the above. Each of these have a given basic ddx. Thinking in this fashion seems obvious, but I like checkbox medicine, so sitting down and writing down and thinking about this stuff helps consolidate your thinking and history taking.
That data gathering, so that your seniors and attendings have what they need to come up with good plans, is essential. So just doing a good job of covering your HPI, ROS, PMHx, also does a lot for them. Because there's nothing more annoying than not being able to make a plan because you have to go actually talk to the patient just to ask a simple pertinent ROS q, when you're an upper.
4) PE
I have a system for VERY quickly recording PE findings in the AM, because trying to keep track of what all the lungs sounded like and on what side for all 10 patients, even if only a few were abnl, was beyond me early on. The way I recorded that made that part of my presentations MUCH smoother. Let me know if that interests you.
I find the most nitpicky exam to not miss things and to record, to be the neuro exam. I had a pocketcard that helped with this. I had Maxwell's because it's cool and has a Snellen on it. I had a dot phrase template that was *just* the more detailed neuro exam and was easy to modify to record abnl findings. I would insert that more detailed PE section where needed. I had PE dot phrases that were customized to the rotation or note type at hand.
5) Communication & Notes
Organization and checkboxing will help your communication. What are the issues with your communication at this point?
Remember you want to be safe, fast, pleasant, in that order. OTOH, it's important to be liked. Go with being liked over trying to look smart. Above I discuss how to ask seniors for help and feedback. It's essential as a struggling resident that you ask for help and feedback early and often. You would think they would tell you if you're on the chopping block, but sometimes they don't. OTOH, if you are that resident, someone will often at least tell you so if you ask.
During my first presentation to an upper or senior I didn't know, when I got to Vitals, PE, Labs, I would take a breath and ask if they always wanted values on vitals, or if they wanted me to say "normal" for each, or even just say the ones that were abnormal. Same with PE, do they want you to say something for each section, or just pertinent findings? Same with labs. Some attendings do want you to list every single value. You'd think they'd just stop and tell you but they don't always, instead they sit and glare at you, this way you also show that you're trying to be proactive about better presentations.
That's all I got. It was a weak point for me, and it seems most difficult to figure out how to get better with this, but I think you will.
My notes were taking a lot out of my hands to type - my senior had a trick for abbreviating words in Epic but having them spelled out in the note anyway. Seniors had various templates. You can get with IT/Epic/EHR helper people to figure out time saving things regarding dot phrases, tabs, and if you see a template of someone's you like, you can often find it and steal it for your own without having to ask anyone about it. There's also a way to create your own template where you just hit tab and then click on a whatever of a number of drop down choices. This made my PE notes both extremely quick and easy, but also detailed enough for honesty, billing, and keeping good track of things.
Good templates can really help your organization, not missing things in your history and PE.
6) Plans
So what you don't remember U2D? For now just use it to figure out what to do. Things will start to stick, I promise.
Safety - here's a few ideas. One is that I carried the Top Clinical Problems in Emergency Medicine (I think that's the name) pocketbook that you can get cheap from EMRA site. It's not a bad thing to have on hand so that you consider emergencies and what to do. (Seniors and attendings alike liked it, and would steal it at times even during codes). If I was scared it was reassuring, and then it let me know I had time to consider all the non-emergent things and the patient probably wouldn't die as I did so.
Also, that no matter what, there are always orders that you can safely put in on your patients - do those. You can hold off on the others to ask your seniors. The first step of not killing the patient isn't a bad one.
When doing an admit, I discuss in a post linked above, a trick from a senior so you can get orders in quickly and get the patient upstairs without being too worried you've overstepped on orders. Things you're struggling with, the more specific a question you have to the senior, the better tips they can give you. I wasn't getting patients upstairs and staffed quickly enough - so my senior shared how they do it faster which I discuss.
I relied a lot on references I could carry too - Sanford Guide as I said, PocketMedicine, EM book. The Clinician's Guide to Laboratory Medicine had algorithm pages I liked.
I have pocketcards like the COPD Pocket Consultant & EMRA Clinical Prediction Card - very useful Wells Criteria PE & DVT, and PE r/o criteria, and PORT score. Although you could just find those - the card also has Ottawa ankle, foot, knee, Nexus and Canadian spine, CT Head. All of which can help you on rotations and clinic depending. I used the PE/DVT portion almost daily it felt like.
The ACLS Acute Coronary Syndromes and Stroke is good too. My 3rd year senior going into critical care at a prestigious fellowship program used to snag my ACLS Cardiac Arrest, Arrythmias, and Their Treatment card when they were on call. I felt better having it.
Maybe I should have said first, I think it's good before a rotation to look up an "Intern Survival Guide" for it online. You can find free ones. Somewhere on SDN as well people suggest those sorts of resources for whatever rotation is at hand. It helps immensely.
As for anchoring, a key thing is to come up with a good ddx to help you not do things. Sometimes anchoring happens because you're just not pulling off the top of your head enough possibilities. This is where the EM book, PocketMed, or U2D can be helpful to look over, as well as a good system to guide your history taking.
One of my posts above discusses a list of topics, like DM, COPD, musculoskeletal issues, that you want to review ddx & basic plans for each.
MedCalc, USPTF phone app, other phone apps and calculators, can be really useful.
7) EKGs
My weak point as well. People like Dubin's and it's a fairly quick read. People don't like Dubin's because he was nailed for child porn. EKG pocketbrain is an option. I have a 12 Lead EKG Quick Reference Guide. Lilly's Pathophysiology of Heart Disease has a section I like.
8) Conclusion
I think identifying weakness as you have is a good thing. My advice as well is to figure out what seems to be holding you back time/efficiency wise, and then come up with a plan to address that. If it's EKGs, then you get references and study them when you've carved out time by getting your note templates tweaked and faster. For me at one point I felt like just typing was an issue, so I spend 5-10 min a day in a free online training app until between work and the practice it sucked less.
I apologize for the long post. I hope it's not overwhelming. I hope it gives you some real ideas/strategies for getting better besides a pat on the back that it will all be OK (not criticizing anyone here or anyone that will have words of encouragement). You don't have to implement everything overnight.
I have more practical tips should you need them, and tips for NF. Just ask where you would like me to expound.
Good luck, remember that you can be more helpful to the team than you think, even if you're struggling on plans. There are concrete ways to address knowledge we can discuss, and that part will come with time.
