Intern AMA - ask us anything

[NickNaylor]

After banging out roughly 60 hours in four days this week, I finally have a day off and have been wanting to do this for a bit. Previous threads here:

MS1 - http://forums.studentdoctor.net/threads/ms1-q-a.929521/
MS2 - http://forums.studentdoctor.net/threads/ms2-ama-ask-us-questions.1001936/
MS3 - http://forums.studentdoctor.net/threads/ms3-ama-ask-us-questions.1073816/
(guess I didn't make one for MS4... my bad)

What kinds of questions do you have? This is meant to be less of an application advice thread and more of a learning about life as an intern and the more "intangible" aspects of the experience that you might be curious about if you're interested in getting into medical school or in the midst of applying to medical school now.

For background: I'm a psychiatry resident but am currently on an inpatient internal medicine service. So far I've rotated in the psych ER at a large county hospital and an inpatient substance use unit at the VA, both for a month. My current rotation is at the aforementioned large county hospital.

I would encourage any other interns to join in with their experiences as well.

So, ask away - what kinds of questions do you have about the enigmatic, soul-sucking intern year?

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[CellPowerhouse]

How many hours of sleep per night are you averaging?

 

[NickNaylor]

How many hours of sleep per night are you averaging?

For my first month, I was working nights and switched to a nocturnal schedule for a month. It took me about 3 weeks (out of the 4 for the rotation) to fully adjust, so I was sleeping about 5-6 hours a day most of the time. That was really more because I had trouble sleeping during the day than because I had limited time to sleep.

For my second month, we had lectures at 7:00a three days of the week and would have to be in by 8:00a or so the other days. The VA was a further drive for me so I had to get up earlier than before. I'd say I averaged about 6-7 hours of sleep a night.

Currently, I have to get up pretty early to get to the hospital on time to pre-round. Part of this is because I'm pretty inefficient since it's been roughly two years since I've done medicine. Just in a week, though, I've relearned the ropes and am getting faster, so I finish up and go home earlier (unless I'm on call) and don't have to get to the hospital as early. I'd say I'm averaging 6-7 hours/night.

 

[Lucca]

How much time do you spend studying while not at the hospital, if at all? Has your method of working/practicing medicine changed significantly across practice settings (VA, ER, hospital) and was that due more to patient population, workplace structure, teammates, etc?

 

[Clark_Griswold]

Noob question here: Does intern year look fairly similar regardless of what residency you have chosen? Or is it more tailored to the path you're on?

 

[HybridEarth]

When you go home, what do you do? Do you have to work from home often, or are you truly able to just do whatever you want when you're not at the hospital?

 

[NickNaylor]

How much time do you spend studying while not at the hospital, if at all? Has your method of working/practicing medicine changed significantly across practice settings (VA, ER, hospital) and was that due more to patient population, workplace structure, teammates, etc?

I try and read regularly but it's nothing like it was in medical school. Since "exams" aren't really a thing, reading is more so that you can provide well-informed treatment for patients than it is to do well on tests. Consequently, reading is obviously important. However, if I spend a lot of time at the hospital I'm not going to stress about reading that night when I get home. There's also a lot of "on the job" learning that happens. Picking up little points here and there adds up to a lot when you're in the hospital a ton.

There's definitely a difference, but most of it has to do with administrative stuff than anything else. Nursing issues also vary across settings. In the VA, for example, getting appointments for patients for follow-up is much easier than at Big County Hospital (which you can't even put appointments in for, just referrals - the patient has to call to set up the appointment). Nursing also varies widely and among individual units. The nurses I worked with in the ED were generally solid. The nurses I worked with at the VA were awful, and one actually told my attending, "he's crazy and is going to be a bad doctor" because, as far as I can tell, I reminded her three days in a row to give a medication that had been ordered and she wasn't giving. The nurses on my current rotation are also equally bad, and orders somewhat frequently go ignored, it's impossible to get things done, etc.. That doesn't so much affect how I "practice" in as much as it causes me to waste a lot of time doing things that I really shouldn't have to if people just did their jobs. If a practicing physician doesn't order, say, an antibiotic and bad things happen, that's malpractice. If a nurse doesn't draw labs or if diagnostic testing doesn't get done despite being ordered, that's just an "oops." I would say that more than half of my time on my current rotation that isn't spent rounding or seeing patients is trying to get things to actually happen. The VA was a similar story.

I haven't yet rotated at my program's private academic hospital, which I've heard is magnitudes better in these regards.

 

[NickNaylor]

Noob question here: Does intern year look fairly similar regardless of what residency you have chosen? Or is it more tailored to the path you're on?

Depends. Surgery and medicine tracks are generally similar, though some pathways that are categorical (i.e., integrate an intern year with the actual specialty training) will have rotations specific to your field in addition to more general things. In contrast, dermatology, for example, generally requires you to complete a pre-lim year which is either internal medicine or surgery and has nothing to do with dermatology, after which you go on to dermatology-specific training. In that case, a dermatology "intern" and an internal medicine intern are essentially doing the same thing.

In psychiatry, the intern year is composed of 6 months of "on-service" psychiatry rotations and 6 months of "off-service" non-psychiatry rotations, which are usually four months of medicine/pediatrics and two months of neurology.

 

[NickNaylor]

When you go home, what do you do? Do you have to work from home often, or are you truly able to just do whatever you want when you're not at the hospital?

Depends on the rotation. The ED was pure shift work, so when I left I didn't have to do anything. It's difficult to get VPN access to the VA's EMR system, so even if I wanted to work from home I couldn't on that rotation. However, most evenings I would have to spend a small amount of time updating our patient list and making sure the information is correct. On my current rotation I will usually check up on patients at night so that I don't have to do as much of that when I get in the following morning. Since I was off today, for example, I'll check up on my patients later this evening to see what happened and if anything changed so that I'm not lost when I go back in tomorrow. I'll also complete things that aren't time-sensitive (e.g., discharge summaries) from home if I didn't have the chance to get to them during the day.

Most of the time, though, I haven't had to do much work from home apart from reading when I have the chance. But I consider that less "work" and more "learning."

 

[NickNaylor]

Depends. Surgery and medicine tracks are generally similar, though some pathways that are categorical (i.e., integrate an intern year with the actual specialty training) will have rotations specific to your field in addition to more general things. In contrast, dermatology, for example, generally requires you to complete a pre-lim year which is either internal medicine or surgery and has nothing to do with dermatology, after which you go on to dermatology-specific training. In that case, a dermatology "intern" and an internal medicine intern are essentially doing the same thing.

In psychiatry, the intern year is composed of 6 months of "on-service" psychiatry rotations and 6 months of "off-service" non-psychiatry rotations, which are usually four months of medicine/pediatrics and two months of neurology.

I should add that, in summary, individual programs and fields do have different intern years. However, there are some similarities among them in that most surgical specialties will do some amount of general surgery training and most medical specialties will do some amount of internal medicine training. The question is how much and in what setting, which will vary from field to field and even program to program.

 

[TaroBubbleTea]

Not about intern year per se, but I'm curious as to how you decided on your current specialty. Did you always want to do psychiatry? If not, how did you go about narrowing down which field you wanted to go into?

 

[sovereign0]

Is there anything you wish you knew as a medical student? Pre-med? Any words of wisdom for us plebians?

 

[mimelim]

Just stopping by to say hi. I remember when I made this thread as an intern and how time someone increased it's pace 5 fold. Enjoy it Nick, hours are going to suck, but you are going to learn so much

 

[NontradCA]

Do you feel like a doctor?

 

[Lucca]

I try and read regularly but it's nothing like it was in medical school. Since "exams" aren't really a thing, reading is more so that you can provide well-informed treatment for patients than it is to do well on tests. Consequently, reading is obviously important. However, if I spend a lot of time at the hospital I'm not going to stress about reading that night when I get home. There's also a lot of "on the job" learning that happens. Picking up little points here and there adds up to a lot when you're in the hospital a ton.

There's definitely a difference, but most of it has to do with administrative stuff than anything else. Nursing issues also vary across settings. In the VA, for example, getting appointments for patients for follow-up is much easier than at Big County Hospital (which you can't even put appointments in for, just referrals - the patient has to call to set up the appointment). Nursing also varies widely and among individual units. The nurses I worked with in the ED were generally solid. The nurses I worked with at the VA were awful, and one actually told my attending, "he's crazy and is going to be a bad doctor" because, as far as I can tell, I reminded her three days in a row to give a medication that had been ordered and she wasn't giving. The nurses on my current rotation are also equally bad, and orders somewhat frequently go ignored, it's impossible to get things done, etc.. That doesn't so much affect how I "practice" in as much as it causes me to waste a lot of time doing things that I really shouldn't have to if people just did their jobs. If a practicing physician doesn't order, say, an antibiotic and bad things happen, that's malpractice. If a nurse doesn't draw labs or if diagnostic testing doesn't get done despite being ordered, that's just an "oops." I would say that more than half of my time on my current rotation that isn't spent rounding or seeing patients is trying to get things to actually happen. The VA was a similar story.

I haven't yet rotated at my program's private academic hospital, which I've heard is magnitudes better in these regards.

Thanks for answering. That's really interesting actually, and a shame. I haven't spent nearly as much time in a practice as you have as an intern obviously but I've never heard someone complain about such nursing etiquette! Especially letting things go undone. That's rough, I wonder if I've been sheltered in my experiences.

 

[Nymphicus]

Do they treat you differently than the categoricals?

 

[Cyberdyne 101]

@alpinism, I'm assuming you're also an intern at this point. How's the NYC hospital life? Has med school prepared you well for the challenges that you face on a daily basis?

 

[smarts1]

Being an intern now, what do you wish you did/had known during your clerkship year?

 

[NickNaylor]

Not about intern year per se, but I'm curious as to how you decided on your current specialty. Did you always want to do psychiatry? If not, how did you go about narrowing down which field you wanted to go into?

I had no idea what I wanted to do. I don't have any physicians in the family or anything like that so I was pretty open. I really liked pediatrics in MS3 and had planned on doing that but ended up liking psych more.

Most people make the surgery vs. medicine distinction relatively early, so that's probably the first step in terms of deciding what you want to do. I would just recommend keeping an open mind and being willing to explore things you might be interested in. You'll have plenty of time to shadow during MS1/MS2 so I'd recommend doing that to explore your interests, especially if it's in a field that isn't something you're likely to rotate in.

Short of that, be candid with what you're interested in and what your priorities are and be willing to explore fields.

 

[NickNaylor]

Do you feel like a doctor?

I introduce myself as Dr. Naylor now, I guess that's cool?

I definitely felt like one when I did night float. The decisions I had to make were minor for the most part, but I acted pretty much independently without running things by my attending beforehand. I'd say I felt like a doctor then.

 

[NickNaylor]

Do they treat you differently than the categoricals?

On medicine, not really. Though I do think there's an understanding of "oh, that guy's in psych" which makes them a little more forgiving of mistakes. But it's not as if they're giving me easier patients, fewer patients, etc. just because of that fact. I'm doing the same things the other intern on my team is doing.

 

[NickNaylor]

Just stopping by to say hi. I remember when I made this thread as an intern and how time someone increased it's pace 5 fold. Enjoy it Nick, hours are going to suck, but you are going to learn so much

It's really been great so far - I'm definitely enjoying it, even the off-service rotations. It's more stressful and busier than medical school but a thousand times more satisfying.

 

[NickNaylor]

Is there anything you wish you knew as a medical student? Pre-med? Any words of wisdom for us plebians?

No, not really. I would just say to be proactive and take ownership of your patients when you're on your clerkships, even if that may not be what's expected of you (hopefully it is, though, if your medical school is any good). Residency is really much of the same thing except with more patients. If you're used to knowing everything about a patient, work to try and understand why treatment plans are what they are, and are willing to read and learn about your patients' conditions, you'll be fine for residency. It doesn't necessarily mean it'll be a cakewalk, and you'll still have plenty to learn, but you won't be incompetent.

 

[NickNaylor]

Being an intern now, what do you wish you did/had known during your clerkship year?

Nothing, really. I thought I had great clinical training and felt prepared for residency and think that I've adapted to the role reasonably well. The points I mentioned above are really the only things I would advise other students to do when they're going through their rotations. Learn as much as you can and "fake it till you make it" as much as you can and you'll likely be prepared for residency.

 

[smarts1]

Any tips on doing well on clerkships? One residents told me that one of the worst med students he worked with was someone who didn't even know her patients as well as he did and he was carrying like 15 patients while she only carried 2!

 

[sliceofbread136]

Least favorite 3rd year rotation? Toughest rotation?

 

[NickNaylor]

Any tips on doing well on clerkships? One residents told me that one of the worst med students he worked with was someone who didn't even know her patients as well as he did and he was carrying like 15 patients while she only carried 2!

Know your patients well, be willing to be helpful to your team (yes, this may include scut - it is immensely helpful and needs to get done by someone), and don't be a tryhard.

 

[NickNaylor]

Least favorite 3rd year rotation? Toughest rotation?

Least favorite was OB/GYN, toughest was probably surgery just because of the hours. I really enjoyed the rotation, though, and in another life I could've been a surgeon.

 

[Winged Scapula]

Thanks for answering. That's really interesting actually, and a shame. I haven't spent nearly as much time in a practice as you have as an intern obviously but I've never heard someone complain about such nursing etiquette! Especially letting things go undone. That's rough, I wonder if I've been sheltered in my experiences.

You've been sheltered.

I just finished rounding at a supposedly high-quality facility on a patient I admitted yesterday for intravenous antibiotics. For some reason, despite the order for a loading dose and then a regularly scheduled dose of the medication, the patient only received the loading dose. Nothing else for the last 24 hours. In addition the consult I put in for has not been staffed.

The response is, as noted above, "oops". The lack of higher order thinking such as, "maybe a patient admitted for IV antibiotics should actually be getting them "seems to be lacking in a number of hospitals.

 

[Goro]

As I'm fond of saying, and this is NOT a slam directed at my learned colleague, but stuff like this makes malpractice lawyers grow fat and rich!

You've been sheltered.

I just finished rounding at a supposedly high-quality facility on a patient I admitted yesterday for intravenous antibiotics. For some reason, despite the order for a loading dose and then a regularly scheduled dose of the medication, the patient only received the loading dose. Nothing else for the last 24 hours. In addition the consult I put in for has not been staffed.

The response is, as noted above, "oops". The lack of higher order thinking such as, "maybe a patient admitted for IV antibiotics should actually be getting them "seems to be lacking in a number of hospitals.

 

[NickNaylor]

You've been sheltered.

I just finished rounding at a supposedly high-quality facility on a patient I admitted yesterday for intravenous antibiotics. For some reason, despite the order for a loading dose and then a regularly scheduled dose of the medication, the patient only received the loading dose. Nothing else for the last 24 hours. In addition the consult I put in for has not been staffed.

The response is, as noted above, "oops". The lack of higher order thinking such as, "maybe a patient admitted for IV antibiotics should actually be getting them "seems to be lacking in a number of hospitals.

Indeed. I used to think the nurses at my medical school sucked, but in comparison they were awesome. They were actually proactive about the care of their patients and while they may have been overbearing at times, it's obvious to me now that they were just advocating for their patients. They would follow things up if things weren't getting done and were extremely reliable when it came to following orders, giving medications, etc. They would see that warfarin had been ordered and if there wasn't also a PT/INR order in, they would page the resident to remind them. If they saw an imaging order was in but the patient didn't go down to get it done, they would page us to let us know. It resulted in a lot of pages but it was extremely helpful.

There's a guy on my service (not my patient) who wasn't doing well and has some pretty bad SIRS/sepsis going on. The intern put in an order to start vanc. The nurse never gave the vanc and the order expired. Did she call to ask about the order? Did she bother letting anyone know that the antibiotic order for the patient in really bad shape wasn't be followed? Nope. Instead, she let the intern figure it out at the end of the day when he realized that nothing had been given. So we had a guy with sepsis just sitting on the floor for ~8 hours not getting antibiotics because the order wasn't followed and no one bothered to let anyone know. Awesome. That's the kind of nonsense we're dealing with on a regular basis on this service. It's extremely frustrating.

Just as frustrating, all of the residents got an e-mail from the hospital VP for Education reminding us that we're "all on a team" and that "the transition to the new hospital has presented us with new challenges" (the new Big County Hospital was opened last week and all patients transferred over the course of 2-3 days). Well, sure, we're all on a team, but it's kind of hard to be on a team when your other teammates don't seem to do much of anything to further the cause.

The inconsistency is also frustrating. If you're going to consistently not do something, great, I can deal with that - I know that I need to double check all of your work because you suck. But when I have to look through individual orders to see which of the many things you decided not to do (which seems to change daily), it becomes extremely frustrating and time-consuming.

And, of course, when I'm walking the wards to go see my patients, there seems to be plenty of time to check e-mail, text people on your phone, talk to other staff, etc. but seemingly no time to follow orders.

 

[moy505]

Forgive the noob question but...What are ppl talking about when they say you can make bank moonlighting and stuff in a psych residency? I heard 3rd year residents get like $100hr for moonlighting. Is it more for attendings? Also is the rate the same during the day time? What is moonlighting? Is it just like giving up sleep completely lol

 

[moy505]

Also why does the psych forum seem to hate Nps? They literally make like 120k less than psychiatrists. and even RNs can make like 80k/yr. Whats wrong with a nurse, that's done additional schooling in psych, making ~20k more than an RN?

 

[NickNaylor]

Forgive the noob question but...What are ppl talking about when they say you can make bank moonlighting and stuff in a psych residency? I heard 3rd year residents get like $100hr for moonlighting. Is it more for attendings? Also is the rate the same during the day time? What is moonlighting? Is it just like giving up sleep completely lol

Moonlighting is basically doing additional clinical work outside of your residency responsibilities which is paid. It requires a full license, which you can generally get after your intern year is completed. Depending on the jobs and hours you can make a lot of money. $125-150/hr is not out of the norm. There are psych moonlighting gigs around here that pay $3-4k for weekend call coverage.

Moonlighting counts toward your 80 hours/week duty hour restrictions so you're limited in how much you can do. Depending upon your field you may not be able to moonlight at all. But if you're able to it can be a lucrative experience in addition to a good learning experience.

 

[NickNaylor]

Also why does the psych forum seem to hate Nps? They literally make like 120k less than psychiatrists. and even RNs can make like 80k/yr. Whats wrong with a nurse, that's done additional schooling in psych, making ~20k more than an RN?

I don't think it's about the money. It's about the quality of care. I don't think there's much faith in the idea that you can go from RN to independent psych practitioner in 3 years and be a solid provider. For management of basic disease processes? Sure. But you'll see that even PCPs get overconfident in their ability to manage things like depression and start completely bizarre treatment regimens because they have no idea what they're doing once they get past starting SSRIs for depression.

 

[Cyberdyne 101]

I don't think it's about the money. It's about the quality of care. I don't think there's much faith in the idea that you can go from RN to independent psych practitioner in 3 years and be a solid provider. For management of basic disease processes? Sure. But you'll see that even PCPs get overconfident in their ability to manage things like depression and start completely bizarre treatment regimens because they have no idea what they're doing once they get past starting SSRIs for depression.

So ideally, should PCPs draw the line at SSRIs when managing depression and/or anxiety?

Oh, and are you going to miss the Chicago winters?

 

[MiaMia14]

For my first month, I was working nights and switched to a nocturnal schedule for a month. It took me about 3 weeks (out of the 4 for the rotation) to fully adjust, so I was sleeping about 5-6 hours a day most of the time. That was really more because I had trouble sleeping during the day than because I had limited time to sleep.

For my second month, we had lectures at 7:00a three days of the week and would have to be in by 8:00a or so the other days. The VA was a further drive for me so I had to get up earlier than before. I'd say I averaged about 6-7 hours of sleep a night.

Currently, I have to get up pretty early to get to the hospital on time to pre-round. Part of this is because I'm pretty inefficient since it's been roughly two years since I've done medicine. Just in a week, though, I've relearned the ropes and am getting faster, so I finish up and go home earlier (unless I'm on call) and don't have to get to the hospital as early. I'd say I'm averaging 6-7 hours/night.

I'd like to point out that this is specialty specific. I'm doing an obgyn internship and I have to be there to round between 5-5:30am depending on how many patients there are. I'm also averaging about 6-7 hours of sleep a night. Our sign out is at 5:30pm which can take anywhere between a half hour and an hour and then I usually finish up any work I have pending. I live a half hour from the hospital, so I usually get home around 6:30-7. I am usually dead tired and fall asleep around 9pm. I am usually just under the 80 hour work week limit.

 

[NickNaylor]

So ideally, should PCPs draw the line at SSRIs when managing depression and/or anxiety?

Oh, and are you going to miss the Chicago winters?

In general yes, I think that's the recommendation. Two failures of adequate trials of SSRIs should warrant a referral to psych unless a PCP is very comfortable with psych drugs and are comfortable with more advanced management. Same thing with anxiety - try an SSRI and refer out if it fails. For all that is holy do not start a benzo for long-term management.

 

[allantois]

Also why does the psych forum seem to hate Nps? They literally make like 120k less than psychiatrists. and even RNs can make like 80k/yr. Whats wrong with a nurse, that's done additional schooling in psych, making ~20k more than an RN?

No one likes incompetent practitioners.

 

[deleted393595]

So, ask away - what kinds of questions do you have about the enigmatic, soul-sucking intern year?

How do you balance residency and maintaining a relationship with your significant other (if you have one)?

 

[sinombre]

How much vacation time did you get during 4th year?

 

[tantacles]

How much vacation time did you get during 4th year?

Oh, come now! This is a question for a fourth year.

I get 12 weeks guaranteed.

4 weeks for doing a longitudinal clinic elective at a free clinic (20 sessions total).

4 weeks of independent study, which I count.

4 weeks of online elective.

So I would say a total of 24 weeks.

 

[NontradCA]

Know your patients well, be willing to be helpful to your team (yes, this may include scut - it is immensely helpful and needs to get done by someone), and don't be a tryhard.

Can you define scut?

 

[NontradCA]

Oh, come now! This is a question for a fourth year.

I get 12 weeks guaranteed.

4 weeks for doing a longitudinal clinic elective at a free clinic (20 sessions total).

4 weeks of independent study, which I count.

4 weeks of online elective.

So I would say a total of 24 weeks.

But at full tuition price?

 

[tantacles]

But at full tuition price?

Nobody tried to tell you it wasn't a scam.

 

[NickNaylor]

How much vacation time did you get during 4th year?

Two weeks vacation, two weeks sick/admin/educational leave. There's a possibility that that will be changed to a total of four weeks of a single pool of time but that hasn't happened yet. I haven't taken a day off yet but I probably will be soon...

 

[NickNaylor]

How do you balance residency and maintaining a relationship with your significant other (if you have one)?

I'm married, so it can definitely be tough. I try to spend as much time with the wife as I can. But there are some things you can't do much about. She's understanding and supportive. But if you have someone who's needy I imagine it would be difficult.

 

[NickNaylor]

Two weeks vacation, two weeks sick/admin/educational leave. There's a possibility that that will be changed to a total of four weeks of a single pool of time but that hasn't happened yet. I haven't taken a day off yet but I probably will be soon...

Wait, sorry. I misread that. I took a total of like... 5 months of vacation during MS4. I only did two months of clinical rotations.

 

[sliceofbread136]

I'd like to point out that this is specialty specific. I'm doing an obgyn internship and I have to be there to round between 5-5:30am depending on how many patients there are. I'm also averaging about 6-7 hours of sleep a night. Our sign out is at 5:30pm which can take anywhere between a half hour and an hour and then I usually finish up any work I have pending. I live a half hour from the hospital, so I usually get home around 6:30-7. I am usually dead tired and fall asleep around 9pm. I am usually just under the 80 hour work week limit.

That's because Ob/gyn is the worst! I am definitely struggling getting used to the hours on my first week of Ob

 

[NickNaylor]

Can you define scut?

Common things we have medical students do that may qualify as "scut" but is still important nonetheless:

-Getting requisition labels for labs because nurses are apparently incapable of sending them to the lab
-Having students follow-up with things like PT/OT/RT and just about anything that involves trying to talk with someone that is impossible to get in touch with
-Doing things like orthostatics, checking a patient's O2 setting when we don't trust a chart, etc.

The fact is that medical students are immensely helpful. I hated this kind of crap as a medical student, but the truth is that it needs to be done and it really helps the team. It really isn't so much that the work is "too low" for an intern so much as it is that medical students are limited in what they can actually do to contribute to the team's work and these kinds of things need to be done but the residents are busy enough as it is responding to pages, putting in orders, writing notes, etc..