- Joined
- Jan 25, 2007
- Messages
- 1,625
- Reaction score
- 21
What sorts of tips or advice would you give for PGY1 interns, particularly regarding cross-cover and/or any considerations for particular diseases or situations?
Most Important Tips/Advice for PGY1s Starting IM Internship
- Thread starter futuredoctor10
- Start date
- Joined
- Apr 28, 2006
- Messages
- 6,133
- Reaction score
- 2,366
1) See everyone you are called about in the beginning of the year. By the end, you will be able to triage and you will know who is sick.
2) look stuff up
3) Don't feel like you are weak for asking for help. It is a sign you are weak if you don't ask for help and actually needed it.
4) When in doubt, bump the patient up to a higher level of care.
5) Look at every EKG, X-ray, lab you order
6) Make a to do list and follow it. It is going to be busy and that to do list will keep you on track.
- Joined
- Dec 14, 2006
- Messages
- 69,368
- Reaction score
- 61,664
Re-posting from 2011, because I think it's evergreen:
"I had a whole year off doing basic science research prior to starting internship, and it went ok. You'll be surprised I think by what you still know. Don't get me wrong it will be a bit of nightmare for the first few months, but that's the way it is for everyone.
You will always have backup. As an intern the first few months your job is not to think much at all, but to simply do as you are told. I would suggest paying attention during this time, because as a PGY-3 come September/October, I'm going to start expecting more . . . for instance IV fluids . . . if you're still asking me on a basic patient you were not paying enough attention, and by January I shouldn't have to do much except make sure the team flows. So in your first few months if you don't know ASK!! No one will hold it against you, I asked all the time about everything when I showed up, BUT I paid attention, so I rarely ever had to ask again. In fact, if I find out you didn't ask when you didn't know, I will breath fire up your ass. Ultimately, I can only be as good a supervisor and teacher as you allow me to be, so use my experience.
Never lie. Never, ever, make up any data. NEVER say, "I think it was X" when you have no ****ing clue whatsoever. If you do this and I find out, I'll never trust you again, and I will breath fire up your ass. "I can't tell you that information" has been one of the most valuable sentences for me during my internship. Did I occasionally meet the ire of an attending, fellow, or senior resident? Sure, but you know what? They knew they could trust me. Just don't miss the information again in a similar situation and no one will even remember the incident but you. "My mistake. That will not happen again." was a close second in value to me. You WILL make mistakes, own them, NEVER do them again.
On IM you really seem to admit like 10 diagnoses regularly, for the most part. It would behoove you to make sure by the end of your first few months that you know how to write the basic admitting orders for any of these frequent admitting problems. By September if I have to tell you the initial management and admitting order for your basic COPD exacerbation, I might yell at you (nicely, as in hey, man, you really should know this by now). Even though some of the pocket books have this information, I kept a separate pocket note pad on which I wrote admitting diagnosis and admitting orders (with variations that were attending specific when appropriate).
Do not fight about consults or admits when called. My job as senior (and the same can be said for the fellows on your sub-specialty rotation) is to protect you and the team from bull****. Let me know you were called, if we're going to fight it, let me do it. There is no reason to get bent out of shape fighting a consult, because I promise as an intern, you'll get mad and try and block for a few hours and then end up doing it anyway, going home late.
Organization . . . some people keep binders. Some people keep a copy of the daily notes for every patient they are following in their pocket. I did not do either, which occasionally got me into some hot water when I didn't remember the magnesium from four days ago, but for me, it was an exercise in training myself to remember what was important without the "crutch" and it has more or less worked. I get to learn what is important information by the withering looks I get when I don't remember and from then on out I do. I would recommend trying the binder method to start with and evolving your organization from there. Throwing everything into a clipboard, sound good on paper, but I think it's a bad idea because you could bump into the wrong person and then it's all everywhere. Clipboards were good for students, not so much for resident, IMHO.
Finally, be social (I have a lot of awesome friends I didn't have three years ago and we're all happy to be moving on and doing what we want but sad to be leaving each other. These are the kinds of bonds that someone who's not been through the residency process will never understand). Which can be tough. For the first month I often only wanted to come home as sleep by 8 . . . but these people are the guys you will be doing this with for the next three years. Organize a liver rounds after work. Going through it together will make it seem much less lonely.
You guys will be fine, I'm sure. If a sorry, poor excuse for like myself can be brought up to snuff, I'm very confident that the rest of you can too.
I found posting SDN helped. FWIW . . ."
"I had a whole year off doing basic science research prior to starting internship, and it went ok. You'll be surprised I think by what you still know. Don't get me wrong it will be a bit of nightmare for the first few months, but that's the way it is for everyone.
You will always have backup. As an intern the first few months your job is not to think much at all, but to simply do as you are told. I would suggest paying attention during this time, because as a PGY-3 come September/October, I'm going to start expecting more . . . for instance IV fluids . . . if you're still asking me on a basic patient you were not paying enough attention, and by January I shouldn't have to do much except make sure the team flows. So in your first few months if you don't know ASK!! No one will hold it against you, I asked all the time about everything when I showed up, BUT I paid attention, so I rarely ever had to ask again. In fact, if I find out you didn't ask when you didn't know, I will breath fire up your ass. Ultimately, I can only be as good a supervisor and teacher as you allow me to be, so use my experience.
Never lie. Never, ever, make up any data. NEVER say, "I think it was X" when you have no ****ing clue whatsoever. If you do this and I find out, I'll never trust you again, and I will breath fire up your ass. "I can't tell you that information" has been one of the most valuable sentences for me during my internship. Did I occasionally meet the ire of an attending, fellow, or senior resident? Sure, but you know what? They knew they could trust me. Just don't miss the information again in a similar situation and no one will even remember the incident but you. "My mistake. That will not happen again." was a close second in value to me. You WILL make mistakes, own them, NEVER do them again.
On IM you really seem to admit like 10 diagnoses regularly, for the most part. It would behoove you to make sure by the end of your first few months that you know how to write the basic admitting orders for any of these frequent admitting problems. By September if I have to tell you the initial management and admitting order for your basic COPD exacerbation, I might yell at you (nicely, as in hey, man, you really should know this by now). Even though some of the pocket books have this information, I kept a separate pocket note pad on which I wrote admitting diagnosis and admitting orders (with variations that were attending specific when appropriate).
Do not fight about consults or admits when called. My job as senior (and the same can be said for the fellows on your sub-specialty rotation) is to protect you and the team from bull****. Let me know you were called, if we're going to fight it, let me do it. There is no reason to get bent out of shape fighting a consult, because I promise as an intern, you'll get mad and try and block for a few hours and then end up doing it anyway, going home late.
Organization . . . some people keep binders. Some people keep a copy of the daily notes for every patient they are following in their pocket. I did not do either, which occasionally got me into some hot water when I didn't remember the magnesium from four days ago, but for me, it was an exercise in training myself to remember what was important without the "crutch" and it has more or less worked. I get to learn what is important information by the withering looks I get when I don't remember and from then on out I do. I would recommend trying the binder method to start with and evolving your organization from there. Throwing everything into a clipboard, sound good on paper, but I think it's a bad idea because you could bump into the wrong person and then it's all everywhere. Clipboards were good for students, not so much for resident, IMHO.
Finally, be social (I have a lot of awesome friends I didn't have three years ago and we're all happy to be moving on and doing what we want but sad to be leaving each other. These are the kinds of bonds that someone who's not been through the residency process will never understand). Which can be tough. For the first month I often only wanted to come home as sleep by 8 . . . but these people are the guys you will be doing this with for the next three years. Organize a liver rounds after work. Going through it together will make it seem much less lonely.
You guys will be fine, I'm sure. If a sorry, poor excuse for like myself can be brought up to snuff, I'm very confident that the rest of you can too.
I found posting SDN helped. FWIW . . ."
- Joined
- Mar 6, 2005
- Messages
- 21,374
- Reaction score
- 17,895
If you can't come up with at least 10 common/frequent diagnoses on your own at this point, nobody here is going to be able to give you the help you need.
- Joined
- Dec 14, 2006
- Messages
- 69,368
- Reaction score
- 61,664
gutonc is a bit cranky today (though he may have a bit of a point) . . . however . . . and some of this may vary by location and practice patterns in the hospital but stuff like, COPD exacerbation, heart failure exacerbation, dehydration, kidney injury, cellulitis, pneumonia, ACS rule-outs, pain control, and gomer status with failure to ambulate and/or home support structure, etc.
Yes, I can. And I'm very confident I don't need a disproportionate amount of help. But a 10 second post seems like a small investment to make sure I'm not missing a big topic.
Also, I can't be the only one to notice the irony of your non-constructive post in a thread emphasising the point that 'honest questions won't be met with contempt'.
Thanks JDH. This is a perfect example of why I asked. This sort of patient at my home institution goes non-teaching, and it's not something I have much exposure to.
dizziness/syncope/pre-syncope/fall/headache/AMS/sickle cell crisis (in this part of the country)/baby-sitting for surgery and the good ole " i just dont feel well"
- Joined
- Mar 6, 2005
- Messages
- 21,374
- Reaction score
- 17,895
So...since I'm less cranky today:
Where I went to med school?
New AIDS dx with PCP pneumonia or Kaposi's sarcoma
Active TB
Malaria
DKA
ESRD needing urgent initiation of dialysis
widely metastatic cancer
DFOIC
Sickle cell crisis
CPROMI with crack pipe in hand on arrival to the floor
High as hell with a broken arm//leg after falling off the subway tracks and ortho won't take them on their service but will consult
Where I did residency?
COPD exacerbation
CHF exacerbation
CPROMI
ESLD
Tylenol OD
Acute exacerbation of chronic O/Q sign sent from NH at 4am
Post-transplant (liver, lung, pancreas, bone marrow, heart) disasters
Widely metastatic cancer
High as hell with a broken pelvis after high speed MVC and ortho won't take them on their service but will consult
Where I went to med school?
New AIDS dx with PCP pneumonia or Kaposi's sarcoma
Active TB
Malaria
DKA
ESRD needing urgent initiation of dialysis
widely metastatic cancer
DFOIC
Sickle cell crisis
CPROMI with crack pipe in hand on arrival to the floor
High as hell with a broken arm//leg after falling off the subway tracks and ortho won't take them on their service but will consult
Where I did residency?
COPD exacerbation
CHF exacerbation
CPROMI
ESLD
Tylenol OD
Acute exacerbation of chronic O/Q sign sent from NH at 4am
Post-transplant (liver, lung, pancreas, bone marrow, heart) disasters
Widely metastatic cancer
High as hell with a broken pelvis after high speed MVC and ortho won't take them on their service but will consult
- Joined
- Jul 28, 2004
- Messages
- 27,964
- Reaction score
- 56,392
Where on earth did you go to medical school, Nigeria?
- Joined
- Mar 6, 2005
- Messages
- 21,374
- Reaction score
- 17,895
Close. Brooklyn.
- Joined
- Apr 28, 2006
- Messages
- 6,133
- Reaction score
- 2,366
Done fellout in church... Classic.
Classic medicine you should know as well as the acute/worrisome things to look for:
Pna
Cellulitis
Copd exacerbation
Chf
Chest pain
NSTEMI
Abdominal pain
Syncope/near syncope
Esrd or worsening renal failure
Hyperkalemia/calcemia
PE
New, undifferentiated dyspnea
Hypertensive urgency
Sickle cell pain crisis and sickle acute chest
- Joined
- May 7, 2009
- Messages
- 934
- Reaction score
- 51
Another tip would be to remember that July is temporary. It was uber painful in the first few weeks, and I recall August/September doing all sorts of jacked up things to my sleep day/night cycle. It ends soon. With this, however, comes the added bonus of no longer being able to use the excuse "It's my first day/week/month."
In retrospect, I wish I had done more reading in months 2 and 3 after the culture shock was over. The transition from n00b to "you'd better be doing 95%+ of the thinking/work" sneaks up on you very quickly.
In retrospect, I wish I had done more reading in months 2 and 3 after the culture shock was over. The transition from n00b to "you'd better be doing 95%+ of the thinking/work" sneaks up on you very quickly.
- Joined
- Sep 29, 2009
- Messages
- 1,603
- Reaction score
- 268
Ha sounds like the stuff we see at county in Houston. Love it
- Joined
- Jan 25, 2007
- Messages
- 1,625
- Reaction score
- 21
thanks everyone for the replies/advice!
- Joined
- Oct 26, 2008
- Messages
- 7,464
- Reaction score
- 4,143
- Joined
- Oct 21, 2008
- Messages
- 2,348
- Reaction score
- 2,305
To add to the above:
GI bleeds
hepatic encephalopathy/liver failure/cirrhosis with 'I need a tap and missed my appointment'
encephalopathy (etiology unclear)
CVA
'grandma fall down go boom' (usually become rocks)
suicide attempts
2nd the 'widely metastatic cancer' above
GI bleeds
hepatic encephalopathy/liver failure/cirrhosis with 'I need a tap and missed my appointment'
encephalopathy (etiology unclear)
CVA
'grandma fall down go boom' (usually become rocks)
suicide attempts
2nd the 'widely metastatic cancer' above
- Joined
- Oct 5, 2006
- Messages
- 4,106
- Reaction score
- 849
CHF/ACS/arrhythmias/CP rule outs
Dyspnea/COPD/PNA/asthma
Syncope/near syncope
AMS
CVA/brain bleeds
Headache
Abd pain/acute abd/hepatitis
GI bleeds
Constipation/diarrhea/colitis
Septic shock
Cellulitis
neutropenic fever
Failure to thrive/placement admits
DKA/new DM/hypoglycemia
Cardiac arrest/post code management
ETOH withdraw/intoxication of various drugs/overdose
Acute psychosis/delirium
Dyspnea/COPD/PNA/asthma
Syncope/near syncope
AMS
CVA/brain bleeds
Headache
Abd pain/acute abd/hepatitis
GI bleeds
Constipation/diarrhea/colitis
Septic shock
Cellulitis
neutropenic fever
Failure to thrive/placement admits
DKA/new DM/hypoglycemia
Cardiac arrest/post code management
ETOH withdraw/intoxication of various drugs/overdose
Acute psychosis/delirium
- Joined
- Dec 6, 2011
- Messages
- 195
- Reaction score
- 17
a thread worthy of monitoring
- Joined
- Apr 25, 2008
- Messages
- 8,793
- Reaction score
- 9,019
CHF Exacerbation (usually 2/2 meth)
Chest pain rule-out (usually 2/2 meth)
Afib with RVR
DKA/HONK
Hypoglycemia
GI Bleed
Hepatic Encephalopathy
Pancreatitis
r/o SBP
Initiation of chemo
Workup of newly found metastatic cancer
Cellulitis
Diabetic foot r/o osteo
HIV r/o funny infection
UTI (+/- sepsis)
AKI
First time dialysis
CVA
TIA
Pneumonia (+/- sepsis)
COPD Exacerbation
Asthma exacerbation
ETOH withdrawal
Psych admission pending medical clearance (usually something like patient found with mild rhabdo, can't go until it improves)
Too weak to go home
Too old to go home
Chest pain rule-out (usually 2/2 meth)
Afib with RVR
DKA/HONK
Hypoglycemia
GI Bleed
Hepatic Encephalopathy
Pancreatitis
r/o SBP
Initiation of chemo
Workup of newly found metastatic cancer
Cellulitis
Diabetic foot r/o osteo
HIV r/o funny infection
UTI (+/- sepsis)
AKI
First time dialysis
CVA
TIA
Pneumonia (+/- sepsis)
COPD Exacerbation
Asthma exacerbation
ETOH withdrawal
Psych admission pending medical clearance (usually something like patient found with mild rhabdo, can't go until it improves)
Too weak to go home
Too old to go home
- Joined
- Oct 9, 2013
- Messages
- 698
- Reaction score
- 467
These were the 10 most common diagnoses where you went to med school? I'm afraid to ask where you went to med school.
That's more like it.
- Joined
- Mar 6, 2005
- Messages
- 21,374
- Reaction score
- 17,895
You don't have to ask. You just have to pay attention to the thread.
- Joined
- Dec 14, 2006
- Messages
- 69,368
- Reaction score
- 61,664
snap!
- Joined
- Dec 14, 2006
- Messages
- 69,368
- Reaction score
- 61,664
- Joined
- Feb 16, 2009
- Messages
- 528
- Reaction score
- 64
He went to school in Nigeria...Duh!
- Joined
- Feb 5, 2013
- Messages
- 60
- Reaction score
- 18
Is having a smart phone more or less expected now? I prefer paper references and will probably keep those in my pockets regardless. But it also seems like the residents I've seen will call and text each other frequently on personal numbers. Getting service to my flip phone on the lower levels of any building is questionable, and texting is not going to happen with the model I have.
- Joined
- Oct 5, 2006
- Messages
- 4,106
- Reaction score
- 849
I'd say for the most part it probably is. While not likely to be "required" I think it's pretty much the standard now and people are just going to assume you have some sort of smart phone when they send you something or text you.
I still prefer a text reference a lot of times and prefer that to reading to on my phone or iPad, but I also have electronic versions of most references if I need quick access.
At least at my shop we rely heavily in texting throughout the day and I couldn't function with just a flip/non-keyboard phone.
- Joined
- Dec 14, 2006
- Messages
- 69,368
- Reaction score
- 61,664
- Joined
- Dec 11, 2012
- Messages
- 375
- Reaction score
- 427
By 2015, we're going to kill all the pagers and have residents secure text with an app. Hopefully, this will also include image texting. For those incoming residents who don't have a smartphone, we'll end up buying them a no-plan Android for cheap.
- Joined
- Sep 30, 2008
- Messages
- 1,402
- Reaction score
- 38
There are apps like Medigram which are secure and you can send messages/images/consults etc... But you have to register with a medical license.
- Joined
- Dec 20, 2007
- Messages
- 46
- Reaction score
- 0
Thanks for the input everyone.
- Joined
- Sep 20, 2004
- Messages
- 6,007
- Reaction score
- 6,711
Chest
Pain
Rule
Out
Myocardial
Infarction
Nursing
Home
you don't know those , but you know what O/Q sign is?
Last edited:
- Joined
- Mar 27, 2004
- Messages
- 276
- Reaction score
- 2
O sign is seen when a long dead nursing home pt arrives w/ their mouth agap. Q sign is seen when a long dead nursing home pt arrives w/ their mouth agap and their tongue hanging out. I had to google it myself, I can't find the source now, it was on some blog.
- Joined
- Sep 20, 2004
- Messages
- 6,007
- Reaction score
- 6,711
well, they're not long dead…otherwise they wouldn't be sent to the hospital…but they are probably not for this earth much longer…
and you know that it isn't a real sign, right…don't document that...kinda like the nice guy or nice family sign...
- Joined
- Feb 16, 2009
- Messages
- 528
- Reaction score
- 64
Not necessarily. I have seen many times nursing home sending patients they know are dead to the hospital do they can be pronounced dead there. These make nursing home numbers look better. I know this sounds ridiculous but such is the reality.
- Joined
- Sep 20, 2004
- Messages
- 6,007
- Reaction score
- 6,711
ouch! but i guess that never gets past the ED…i've never had to accept an actual dead person (has a brain dead person accepted to the micu…massive CVA and transferred for higher level of care)
- Joined
- Aug 23, 2013
- Messages
- 301
- Reaction score
- 188
I just looked up Q sign
A google search pulls up nothing for CPROMI
Like I said - still preclinical here. Thanks for letting me know!
- Joined
- Mar 27, 2004
- Messages
- 276
- Reaction score
- 2
Yes, I was aware it was't a real sign.
- Joined
- Feb 16, 2009
- Messages
- 528
- Reaction score
- 64
Correct- they never make it pass the ED likely. Based on the first responder notes I have read, the 911 call is always because the patient is in cardiac arrest. Sadly, many of these patients end up getting CPR (unless they are DNR) on there way to the hospital although it is known by the nursing home staff that they are dead.
Samsonite sign and Throckmortin still goes in the chart, right?
- Joined
- Sep 20, 2004
- Messages
- 6,007
- Reaction score
- 6,711
lol…I had to google Throckmortin….
Similar threads
