To be an intern in a few months

[AnxiousPhysician]

Firstly I appologize for grammatical and spelling errors.
A little introduction to who i am.
A fourth year non-traditional medical student with a previous Master degree in engineering (really a degree that is worth nothing - just survived through it). I have two kids and a third one on the way anytime in the next month.
My problem is that i am really anxious about intern year.
I was so burnt-out after second year of med school due to studying all the time. I had very little time for anything,
other things that contributed to this were having to take care of two kids at the time 3yrs and 1yr, with my wife working as a tax preparer for oil companies and so we had to juggle through that, living in a one bedroom roach infested apartment. I did quiet well considering the circumstances. I got mostly A's but my class rank was in the top 1/3 (was a little dissappointed with this) worked hard for comlex and usmle. I did really good on comlex but average on USMLE. i wanted one of the competitive specialties that i had a research background in it, with one published paper. so i was done with the allopathic route but still had the osteopathic route. i did rotate through a few sites but dont think that went well.
After completing year two and being burnt-out i decided to not care too much about third year. Most of the rotations were shadowing experiences wrote very few notes, presented very few patients, volume was low, attendings that did not care and very few didactics. So now after finishing my first semester of fourth year, it had dawned on me that I am not ready for intern year. I have started brushing up on things i have forgotten or am weak in but in reality the problem is much more than knowledge. Currently am on a PM&R rotation and realize that i have a problem in

1, presenting patients - i have anxiety doing this. I cannot memorize everything that the patient has, i blank out instantly. i don't know why attendings are so gung-ho on presenting without reading off your note. its not like if i memorize (basically a parrot) that i would know the patient any better.

2. very inefficient in reading notes especially those with 10 co-morbidities, with a ton of medications. what notes do i leave out and which ones do i take into account. some physicians don't bother writing much in their h&p's, there are times when the chief complaint varies from one note to another during the same hospital stay and this is not because there is a new problem but the same problem is explained differently e.g patient comes in complaining of upper extremity weakness bilaterally and then another would read - patient comes in complaining of muscle spasms in the upper extremities. Some medications are ordered without any explanation given in the charts. A patient has a ton of consults. How do you guys go about this, How do you become efficient ? also do you write up all the medications in your notes even those that are prn ? i was told to do that by both the attending and resident although looking at their notes i saw nothing of that sort. How do you read through charts, imaging, labs in a short amount of time.

3. History taking has been such a huge problem as the patient will take me around and around. give me a chief complaint different than the one given to an attending or ER physician. I really hate this. Also sometimes the family will be with the patient and they will say one thing and the patient another thing, not because the patient is delirious or incognitive but just that everyone thinks that they know better than the other.

4.. I have never done sign-offs, admission orders, discharge summaries, or written enough prescriptions to be comfortable doing that.

5. I have not done any procedures like put int IV lines, ng-tubes, rectal examinations, suturing etc mostly because they claim it would be malpractice. Just for the lawyers who may stumble on this forum, my question is that if you continue sewing doctors, you might end up not having anyone taking care of you when you need it. I don't get it - medical students don't get trained on anything and they are expected to magically know these things.

My attending is 70 year old guy who keeps saying that we a synthesized docs now a days, sheltered alot, while they had it the hard way and they learnt alot that way. I am sure at that time there were not so many notes to read through or so many diagnosed diseases or extensive imaging to read through and patients who had their own pharmacies.

For the next three months i am doing ICU -not at a teaching hospital, anesthesia - same place, and ER -most likely at the same place. I live in a city with a big medical center yet i had a rough time finding rotations as a DO - very DO unfriendly. My school is not in the same area though.

Please help me in anyway that may help me. Any advice, any notes for intern year, what helped you guys become effieicnt, anyone share similar experiences and how they made it through. Appreciate it.

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[MedicineMan99]

That's what residency is for- to fix all these weaknesses. No one is really prepared for internship and everyone struggles with different parts of it. Make sure to apply to good residency programs and use the rest of med school to learn all you can.

 

[j4pac]

You sound like a fantastic future radiologist or pathologist. Think about it.

 

[hallowmann]

Now I'm not really one you should get advice from as a second year, but I'll try to give you some and maybe allay some of your fears:

1) After doing a decent amount of inpatient shadowing at even mid-tier academic centers, I can say that interns aren't all proficient in the things that you mentioned. Some were actually pretty bad (and even I could see that as an MS2). Intern year is basically where you actually learn how to really do things well.

2) I wouldn't worry too much about the stuff you talk about in #5. From what I've heard, places are really variable with what they let you do, so in intern year most programs treat all their interns as if they don't know anything.

3) Its good that you recognize your deficits now. If I were you I'd just start repeatedly practicing #1-4 every chance I got. Stay a bit later, come in a bit earlier. If people don't care to look at notes, orders, etc. just practice them anyways, then ask other 4th years what they would do, how they would change them, etc. If you have other students or residents around, get their advice or ask them to show you how to do certain things. You're basically at the best place in med school to just let things fly and try and learn everything you can. No boards, no shelfs, just you getting all the practice and experience you can get.

Anyways, I'll stop here and let the people who've actually gone through it give you better advice, but that's what I've gathered and suggest.

 

[Siggy]

1, presenting patients - i have anxiety doing this. I cannot memorize everything that the patient has, i blank out instantly. i don't know why attendings are so gung-ho on presenting without reading off your note. its not like if i memorize (basically a parrot) that i would know the patient any better.

I think that it's a bit easier as an intern because I feel that I've been exposed to the common disease processes enough times that remembering the pertinent is more automatic. Similarly, as an intern I feel a lot less pressure to present non-pertinent exam items despite doing a full exam. For what ever reason, I feel like it's a lot easier as an intern to present than as a med student. I don't know why.

2. very inefficient in reading notes especially those with 10 co-morbidities, with a ton of medications. what notes do i leave out and which ones do i take into account. some physicians don't bother writing much in their h&p's, there are times when the chief complaint varies from one note to another during the same hospital stay and this is not because there is a new problem but the same problem is explained differently e.g patient comes in complaining of upper extremity weakness bilaterally and then another would read - patient comes in complaining of muscle spasms in the upper extremities. Some medications are ordered without any explanation given in the charts. A patient has a ton of consults. How do you guys go about this, How do you become efficient ? also do you write up all the medications in your notes even those that are prn ? i was told to do that by both the attending and resident although looking at their notes i saw nothing of that sort. How do you read through charts, imaging, labs in a short amount of time.

If you don't know why a medication was ordered, look up the medication. If it still isn't self-explanatory, contact who wrote it or ask your senior or, if need be, ask your attending (always do this last).

Every imaging order requires a reason. "Portable chest x-ray RE: Sepsis workup".

Consultant requests should also have a reason attached. "56 year old male with a history of ESRD admitted for ___, outpatient dialysis M-W-F, needs inpatient dialysis during stay."

Of course the biggest difference between an intern and a medical student in this regards is that as an intern you are the one putting in the orders. You are the one reviewing imaging on the day it's taken. You are the one talking with the nursing staff and the consultants. This makes you much more tied into the hospital stay than you are as a medical student.

3. History taking has been such a huge problem as the patient will take me around and around. give me a chief complaint different than the one given to an attending or ER physician. I really hate this. Also sometimes the family will be with the patient and they will say one thing and the patient another thing, not because the patient is delirious or incognitive but just that everyone thinks that they know better than the other.

Always use what ever chief complaint the patient gives you. Additionally, the phenomenon of historian alternans is well known, don't worry about it. http://forums.studentdoctor.net/threads/minor-inconsistencies.1076492/

4.. I have never done sign-offs, admission orders, discharge summaries, or written enough prescriptions to be comfortable doing that.

5. I have not done any procedures like put int IV lines, ng-tubes, rectal examinations, suturing etc mostly because they claim it would be malpractice. Just for the lawyers who may stumble on this forum, my question is that if you continue sewing doctors, you might end up not having anyone taking care of you when you need it. I don't get it - medical students don't get trained on anything and they are expected to magically know these things.

That's what residency is for.

My attending is 70 year old guy who keeps saying that we a synthesized docs now a days, sheltered alot, while they had it the hard way and they learnt alot that way. I am sure at that time there were not so many notes to read through or so many diagnosed diseases or extensive imaging to read through and patients who had their own pharmacies.

...and my parents walked to school, up hill both ways, in the snow.