Top 10 things to know as a starting intern

Sleep when you can
Eat when you must
Don't F**K with the pancreas



Ed

There was a thread last year about the same thing - pretty useful as I recall. Maybe someone can dredge up the link.

My number 1 tip:

WRITE EVERYTHING DOWN...you will forget all the things you're asked to do as an intern, and until you get the hang of it, have some system to keep track of everything (for example, I use my daily patient list, next to each patient's name go the vitals, I/Os, then boxes filled in with red pen for things to do [crossed off when I do them] and anything the attending tells me to do is also in red pen.).

1) Never lie
2) Realize you will often feel stupid
3) Be nice
4) Embrace scut ... learn how to do it faster and better
5) Almost everything can wait 5 minutes
6) Strike a balance between doing what's urgent and what's important
7) Buy the WashU Surgery Survival Guide (different from the Washington Manual)
8) See #1 in the prior post

Embrace your weakness -- realize that you don't really know much and have an extremely low threshold to call your senior and ask for help.

Avoid verbal orders if at all possible -- go evaluate the patient, document your findings (low Uo, note BP, HR, 12 hours s/p LAR), and write the orders yourself (bolus 500 cc LR over 2 hours). When the attending sees that you examined their patient at 0200 and bolused their LOL, they'll be much happier that they will when they find telephone orders for fluids overnight.

For the first couple of months, forget about a life. Go to work, come home, do your thing, and go to bed. You'll need a couple of months to adjust to the schedule. Accept that you won't have much free time until you get back into the groove of being well-rested with just 4-5 hours of sleep.

Be good to the nurses and they'll be good to you.

Don't be afraid to say, "I don't know, but I'll find out," about ANYTHING (physical exam finding, lab value, past history, radiology finding).

As stated above, NEVER NEVER NEVER LIE. Get caught once and nobody will ever trust you again.

Never complain about being tired...senior residents, who were interns long before the 80 hour thing, will brand you as lazy.

Be nice to everyone in the hospital, at least at first. Everyone, floor nurses, ER residents, radiology techs, have the power to make your life more difficult if you piss them off early.

Help out your fellow interns and residents, be a team player. If someone else has a ton to do, and you are all caught up, ask what you can do to help out. You'll have much more fun this way, make some friends, and you might even learn more too.

Start reading on day one of internship - your learning is far from over when you graduate med school. The learning curve in internship is huge b/c you see so much, so reading during this year makes it stick a lot better than it might have in school.

Go out and have fun as often as possible - it will give you a little memory of what a happy person you were fourthyear of med school.
Now get off this computer and go out and drink - you're not an intern who has to get up early tommorrow, but you soon will be and you'll be longing for the freedom you had fourthyear.

When on call cross covering, no work-up (within reasonable measures) is too small. If in doubt, just run the whole shabang of tests to work something up. You can't be faulted/yelled at for doing too large a work up.

by reasonable measures, don't order any tests that cost more than a few hundred bucks without attending approval (no CT scans for fevers, etc)

One senior told me once "you can't get yelled at for intubating someone at night..." after he got yelled at for not intubating someone with a PO2 of 45.

Good posts above....just to add a few (esp for life in a large county hospital):

If you want it done right, do it yourself.

"Load the boat" as someone mentioned, and don't forget to get their names as they step aboard.

You are your patient's only advocate. Operate in the mindset that everyone else is trying to kill your patient.

Now go grab a beer, you matched.

Definitely agree with "If you want it done right, do it yourself."

Also, internship is hard. It's supposed to be. You'll probably think about quitting at least 100 times before the year is over. Know that most of us have these same thoughts, and most of us make it through.

1. The first few months are going to be the hardest as far as time is concerned. Don't let it get you down; as the year goes on, you'll become more efficient.
1a. Call your family when you need to.
1b. Go to sleep as early as you can until you gt used to five a night.
1c. Exercise.

2. Be nice. It's not just a question of nurses and staff not hating you; if they actually like you, they can make you a star.
2a. Critical care nurses know more than you. Want to be loved? Make it clear that you understand that, and ask them to teach you.
2b. Go and see the patient. Go and see the patient.
2c. The key to discharge is never health. It's placement.

3. The relationship you will develop with your fellow interns is much like the relationship a patient has with his ventilator. Will they be your friends? Maybe. Will you thank God daily for their existence? Yes.
3a. Be friends with them or marry them outright. Do not date them or you will end up miserable.
3b. Don't talk poorly about them to seniors or attendings. It's bad form.

4. Your reputation is the single most valuable asset you have. If you can become known as a solid, dependable, honest person who cares about your patients, you will have a wonderful year. If your fellow interns learn that they can depend on you to make their lives easier when they need slack, your life will be easier. If you gain a reputation for being lazy or rude or traitorous, you will be miserable.

5. Arrogance will kill you. If you ever hear yourself saying, "I'm the doctor, and I say..." Do not finish your sentence, but kick yourself in the head.

6. When in doubt, call your senior.

7. Some people will die on your watch. It will make you nuts. Go with it.

8. Compassion. Compassion. Compassion. No matter how fat, how poor, how irritable, how annoying and neurotic, maintain compassion. These are people and I don't care whether they're compliant or whether they're shooting up right in front of you.
8a. Imagine how you'd react if you had an NG tube.
8b. Drug seeking behavior is not subtle. Complaints of pain should be believed.

9. Yes, some of your attendings are actually insane. No, you won't deserve most of the fury they pass to you.
9a. They will give you conflicting advice.
9b. Stay well away from politics.

10. Every morning, ask yourself, what could kill your patient in the next hour? In the next day? In the next week? In the next year?

11. It doesn't get any easier, but you get orders of magnitude stronger. What begins as the most demoralizing period in my life has become one of the most self-affirming.

Pretty good advice so far...

1. Be agressive about learning bedside procedures. The pgy-2s and 3s will love that you can put in central lines unsupervised. (Plus it's fun.)

2. Read early and often. Read a little every night about anything. Don't restrict your reading to whatever rotation topics you happen to be learning about during the day. This keeps things interesting while still allowing you to pick up a broad range of info.

3. Call an upper year if you need to. But don't be afraid to make decisions. Better to make decisions and be wrong occasionally than to rarely act independently and get in the habit of reaching for the phone every time a problem presents itself. (Unlike the above poster, I do order CT scans without anyone's approval when they are indicated... I have never been chastised for it either.)

4. You WILL get screwed with the worst holiday schedule, the extra call, the crap jobs that no one likes doing, the extra paperwork, the stat discharge summaries... OK, maybe not always, but if it comes down to you wanting vacation at the same time as the pgy-2 or higher, guess who's going to get the vacation? Don't whine. Take it in stride, and realize that no matter how crappy you think intern life can be, the guys who came before you (before the 80 hour week) had it much harder than you do.

5. Don't take **** from people just because you are an intern. If you make a management decision based on sound reasoning, defend it. Sometimes upper years and attendings push you just to see if you know why you did something. Sometimes they just want to f*** with the intern.

6. Nurses can teach you a lot early on. Be nice. But don't be afraid to lay the smack down once in a while if they get lazy on you, or start trying to convince you why you shouldn't order tid wet to dry dressing changes on a patient.

7. If you're gonna lay the smack down on a nurse, yelling and screaming at them is not the way to do it... for a number of reasons. The best way to do it is to just take their name down, ask the charge nurse for an incident report, and take 5 minutes to fill it out right there at the nursing station in front of everyone. Or, if you are away from the floor, page the nursing supervisor and tell her your story. I once had the nursing supervisor go to the floor and start some IV fluids on a patient because the floor nurse told me she was too busy and hung up on me. I never again had another problem getting telephone orders carried out on that floor.

8. Go out and have fun as much as possible. I will go out during the week for an hour or so, have a single beer, and see some good music, or hang with some students/residents/fellows. Sure, I get a little less sleep, but it makes life a lot more bearable when you have little breaks in your routine. If you don't do stuff to break up the routine, you can go weeks or even months where the days just blur together and you start to get strung out. (Yes, I speak from experience!)

9. If you're gonna go to the OR and do a case, PREPARE for it. I bought Skandalakis to review cases the night before, and it makes cases MUCH better when you know what steps you are supposed to do. You can take charge, and you'll know what instrument to ask for and when. Not to mention, cases are way more relaxing and high-yield when you know what it is that you are trying to do. Though sometimes you don't get any time to prepare, and you just have to wing it!

Good luck.

Excellent advice so far. I'll add:

1. Take care of yourself. Dealing with life and death and paperwork can be emotionally draining. Recognize that.

2. Relax. You are not the one who might die in the ICU tonight. Keep the patient's best interest in mind, but realize you are still going home in the morning.

3. Do what's right. Always.

4. A year lasts 365 days. A day lasts 24 hours. Internship will end. Focus on the most urgent task at hand, don't think too far down the road.

5. They can't actually kill you. They can hurt you, but they can't kill you.

They can't stop the clock.

They can always hurt you more.

The patient is the one with the disease.

There is no body cavity that cannot be reached with a 14 gauge spinal needle and a strong arm.

The first thing to do at a code is take your own pulse.

Placement comes first.

Sometimes you eat the bear; sometimes the bear eats you.

Don't mess with the inevitable.

**Many of these are stolen from The House of God by Samuel Shem.

Always ask yourself, how will my actions today sound in M&M conference next week.

Determine your institution's culture as soon as possible. Some places encourage early autonomy by interns, others don't. If you are at a place where they don't want interns ordering a CT without talking to an upper level, make sure you conform. Otherwise you will get a rep for "acting too independently"

Yes the nurses can be very helpful. However be careful...they don't always know as much as they act like they know. I saw an intern get burned for doing what the nurse wanted when it wasn't indicated. When the nurses tell you the pt needs "X", evaluate carefully before you proceede.

When cross covering for pts who are not on your service, make sure to write a note detailing what you were called for, PE, vitals and actions.

When writing your pt's orders, make sure you cover prn stuff (tylenol, phenergan, ambien, etc) Also don't forget to include colace and a suppository for any pt that you put on narcotics. This will save the on call person many calls and they will love you. If your upper level scrubbed a case and wrote admission orders, you get bonus points if you check and make sure these things are included, as since the upper levels no longer get called for these things, they often forget to write them.

Realize you will feel like a total idiot for the first several months. (espeically if you're not staying at your med school program). Keep a small notebook to write down all the logistics issues as you learn them (phone numbers, common forumlary meds, etc)

Utilize the pharmacists as a great resource for assistance with medication dosing. Learn early on which common med categories are formulary (PPI, abx, etc) also learn which abx require ID approval


Call consultants early in the day (even though no one hesitates to call a surgery consult at 5pm for a pt who has been in the hospital and had a surgical issue for days.) Be polite to folks who call you for consults. Yelling at the peon who is designated to call you won't help.

Realize that the students get to go to the OR more than you do.

It's fun to have students. Make sure you teach them something. Many schools don't give a very good (or any) idea what to put in notes (and those that do ignore things pertinent to surgical pts). For those students rotating with you in July, take time in the first couple days to go over their notes with them. They will love you.

The best reputation you can have is that of a hard worker. This is also the easiest reputation to achieve. Interns are fairly invisible, and pretty much only stand out for doing really dangerous things or for how hard they work (or don't work). Most of the little mistakes you make that will cause you to kick yourself over and over wont' be remembered.

Keep up with your dictations as you go. Nothing is more painful than spending several hours in the bowels of medical records catching up on dictations from two months ago. Do them while the pt is fresh in your mind. It won't take long for the process to become fairly easy and fast.

Above all, even though generally being an intern sucks, it's pretty cool to be a surgery resident. You will have a few moments when you handle some small issue and are treated like you did some major big thing by non surgeons (like replacing a j-tube that was pulled out...these things are very mysterious to non surgerons)

Originally posted by supercut
Determine your institution's culture as soon as possible. Some places encourage early autonomy by interns, others don't. If you are at a place where they don't want interns ordering a CT without talking to an upper level, make sure you conform. Otherwise you will get a rep for "acting too independently"

Yes the nurses can be very helpful. However be careful...they don't always know as much as they act like they know. I saw an intern get burned for doing what the nurse wanted when it wasn't indicated. When the nurses tell you the pt needs "X", evaluate carefully before you proceede.

When cross covering for pts who are not on your service, make sure to write a note detailing what you were called for, PE, vitals and actions.

When writing your pt's orders, make sure you cover prn stuff (tylenol, phenergan, ambien, etc) Also don't forget to include colace and a suppository for any pt that you put on narcotics. This will save the on call person many calls and they will love you. If your upper level scrubbed a case and wrote admission orders, you get bonus points if you check and make sure these things are included, as since the upper levels no longer get called for these things, they often forget to write them.

Realize you will feel like a total idiot for the first several months. (espeically if you're not staying at your med school program). Keep a small notebook to write down all the logistics issues as you learn them (phone numbers, common forumlary meds, etc)

Utilize the pharmacists as a great resource for assistance with medication dosing. Learn early on which common med categories are formulary (PPI, abx, etc) also learn which abx require ID approval


Call consultants early in the day (even though no one hesitates to call a surgery consult at 5pm for a pt who has been in the hospital and had a surgical issue for days.) Be polite to folks who call you for consults. Yelling at the peon who is designated to call you won't help.

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In general, excellent advice. I do take issue with the routine ordering of Colace, or more specifically suppositories, especially those with laxative/cathartic properties. Many services, especially Colorectal do NOT want their patients artifically stimulated (a suppository is a bad idea if the patient doesn't have a rectum, BTW). If you are cross-covering try and get an idea of what things are "banned" on other services. While it may seem artificial, petty and even mercurial, the attendings and/or senior level residents have their reasons and you will save yourself or your fellow intern (when you sign out in the am) some grief if you clarify these things. We have services where Phenergan is banned, others where Toradol is ok and some who believe it to be sure-fire death, etc.

To that end, as the above poster suggests, I would encourage you to check the orders - if your patient is allowed to have PO or RTC Zofran or Tylenol, etc. make sure its written. Your fellow interns will love you for not subjecting them to midnight calls for Ambien. And it is true, senior residents have not been in the trenches for awhile and may well forget to write for an anti-emetic (or even pain meds and MIVF - I've seen it), Foley to gravity, etc. Check their orders - besides if you didn't operate on the patient, it will give you a better feel for the management plan.

I found the nurses, especially SICU ones, invaluable but I can vouch for several instances when I did as a nurse asked because "Attending X likes it this way" (how was I to know?) or because the other team did it earlier, or the patient wants it...etc. and got burned. Only one time did the nurse call the attending and tell him that he (the nurse) had told me to give the order for Hespan because he knew he (the attending) preferred it for his patients. I was extremely grateful because it only yielded an explanation of why he (the attending) hated Hespan rather than a severe whooping. But that almost never happens. Think it through, ask some others and if in doubt, call the Chief and ask.

I made the mistake of not calling because I wanted to be independent, was scared of waking the Chiefs up (we had some yellers in those days) and didn't think I needed to. No great harm came of it (as far as I knew) but it created some tense moments and perhaps a reputation that probably lingered far longer than any anger over being called in the middle of the night for something trivial (or not).

Yeah, be careful with the nurses... Treat them respectfully, but they don't always know more than you do. And if you mess up because you listened to them, you're in trouble.

I think everyone goes around saying "the nurses know more than you do" just to sound ironic and clever. However, there is no basis for this.

Certainly, they know more about nursing issues and how the hospital works. But, most don't have the background to solve complex problems or give meaningful input. They may know the right answer sometimes, but they really couldn't tell you why. Fine on simple patients, but a killer on complex ones.

1) write good orders....
2) if you have patients who are critical and you have to be on top of it and you have lots of patients write the following Nursing orders:
" Notify the Resident Oncall beeper #911 with Blood pressure readings in 1 hour"
This will help you to keep on top of your patients by using the work of RNs and other staff. This does not replace your personal evaluation of patients but when you are busy this helps a lot.

3)maintain a cordial relationship with the staff...They can only help you...
4) train your students to help you too. They can run and get reports and stuff.
5) this may not be so important but I used to use my cellphone from the bathroom when I am in there To answer the pages. This sounds little crazy but that helps to build the reputation of being dependable. the biggest complain about bad intern is not being available when you are really needed.

6) be clear about your communication with others.
7) if you delegate something make sure you tell them to call you back with the info right away.

8) prioritize your patient assignments. place a little box next to it and check it when it is done. It helps you keep on track of what you have done or not.

9) make use of medical students.. Dont be so fast to get mad on them.
Education means teaching more than science it is teaching the general attitude of responsibility and respect for the profession.

10) always teach and ask if you don't know.
11) don't be lazy...your lazyness can cost lives.
12) in critical patients check when you order something...don't rely on students when official report is not available you check yourself make a habit of it...you can prevent disasters.

13) during Scrubbing don't talk or socialize too much with the attending or the student. You are not in a country club when you are operating.
I had medical students joking and I used to tell them you are assisting in operation so pay attention and ask questions if you have ....We don't need jokers really specially during surgery. You are there to help the attending to accomplish a goal and more helpful you are more the attending will teach you.

14) don't be afraid of crazy attendings...the crazier attendings tend to mellow afterwards when you prove you are good and dependable.
I had attending yell and say you are the dumbest resident I have seen in my entire life...and guess what few months later I loved working with him...

15) don't dream about fellowship or don;t dream about next year.
Surgery residency is day by day business....you don't build the light but you pave the road on a daily basis.

16) make index cards of your preops....one by one..and maybe give it to the chief in the morning with all the numbers.....So he looks good when he is about scrub. YOu can be his right hand then you will get lots of credit....

17) listen more....and I have seen so many run their foolish mouth....
Never get too comfortable in any situation...Surgery residency is training leaders...

18) concentrate on your year...do your yearly papers early....
Do like 10-15 test questions of in-service daily and 45 min of reading daily
this will help to reflect your knowledge in in-service and guess what when time comes your doors will open for good fellowships.

Vukken99 said:

Do like 10-15 test questions of in-service daily and 45 min of reading daily
this will help to reflect your knowledge in in-service and guess what when time comes your doors will open for good fellowships.

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where do you get test questions to prep for the in-service?

don't tell me you don't know this.

Ifyou become member of ACS or even for non-members they have like
A CD set to practice for your knowledge for the in service.
I dont recall the name but they come in bunch of CDs.

Plus many do Rush but I find it so lengthy almost like reading a textbook.

For basic surgery book: I like the Greenfield the big one. easy reading.
I like the Gastric Cancer Chapter a lot on latest numbers.

You can test if you someone is reading just asking about the incidence of Gastric Cancer in the world.

Like they say the top is Russia, then Costa Rica and Third is Japan..

And, also what I liked was how the incidence of Gastric cancer is down in the US but some type of gastric cancers by location have increased and it occurs
at younger age....

But, most of in service like to ask about complications of common procedures.
Tons of ICU and pediatric surgery questions. Some trauma surgery stuff like massive liver laceration what you do type of thing....answers like pack and close resuscitate in ICU the reoperate when patient is hemodynamically stable.

Also one good operative anatomy book is very important since less of big operations are performed these days so many young guys forget about anatomy for surgery....

For ICU, Dr Marino's ICU book is very good.

people like vukken are the reason general sugery sucks. sounds like you take yourself a little too seriously. anyways, i am glad that i never have to be your junior resident.

I am a DO
I interviewed in few cathegorical spots for MD gen surgery.
I even got some stupid questions from one of interviewers a CT surgeon MD from harvard guy.

he was telling me what was DO and I told him just like MD but little more in the curriculum and he was very offended.."he jumped and said little more than MD??
what do you mean.?" I said same curriculum more physiotheraphy stuff but pure politics between AOA and AMA stuff democrats VS Republicans. He was very pissed off some old timer from harvard. ahahaha

Then the Director was like I would give you a chance we never took a DO before and I was like playing the violin......and almost sobbing Joke.....

Vukken99 said:

I am a DO
I interviewed in few cathegorical spots for MD gen surgery.
I even got some stupid questions from one of interviewers a CT surgeon MD from harvard guy.

he was telling me what was DO and I told him just like MD but little more in the curriculum and he was very offended.."he jumped and said little more than MD??
what do you mean.?" I said same curriculum more physiotheraphy stuff but pure politics between AOA and AMA stuff democrats VS Republicans. He was very pissed off some old timer from harvard. ahahaha

Then the Director was like I would give you a chance we never took a DO before and I was like playing the violin......and almost sobbing Joke.....

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This post is not meant to be a personal attack but could you make your posts more coherent. This is an interesting thread but I am having some trouble following some of your posts.

I'm gonna agree with Cassidy here. It sounds like you feel like you have to prove something b/c you're a DO or something?!? Good grief man.

It was not a proof or any rivalry against MDs.

It is just a fact that some old timers even young guys are prejudiced either because you are a DO or someone is IMG.

I am just saying we can't continue living in a box forever.

We have to communicate....

I am just talking about the issue of respect among physicians.
Like basic manners..

I even heard of a DO from my school who had to endure like 7 years to finish general surgery not because he was bad or incapable but his MD chairman would not graduate him....because he did not want DOs coming out as Surgeons.....

my comment had nothing to do with you being a DO. i was simply trying to say, as nicely as possible, that you seem to be generally unlikable and rigid.

Cassidy61 said:

my comment had nothing to do with you being a DO. i was simply trying to say, as nicely as possible, that you seem to be generally unlikable and rigid.

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I too was speaking about his unlikable nature but just took a stab and maybe why that is the case...

I'm sure I'll step on some toes here but it doesn't seem like a big stretch to understand why some MD guys look at DO's differently. Just one example of the difference is the admissions standards. When I was in college I think DO schools averaged 8's on the MCAT and maybe 3.4 or so GPA. That is quite different than the average allopathic school. None of this means there aren't some very talented people in DO school (my college roommate is one of them) butsurely you can understand why someone might feel the way they do.

Well let me share my numbers and no lie:

I scored 30 on MCATs back in 96, with My Four year GPA 3.87.
I graduated with Magna Cum Laude with double Major but I skipped my graduation. So you guys can feel my nature....

So I always say those numbers are wrong...

I did i had friends with lowers scores in allopathic med schools.

But I did not have any research on my belt since I was going to college at night and working full time during the day....

I remember being little pissed off with my undergrad bio department since somehow they would not accept research assistants part-time...

What a stink that was but I did volunteer on a level I trauma during Friday, Saturday and Sunday nights helping the staff. This same hospital interviewed me later for cathegorical gen surgery slot...So strange that is....

During my interview, the Co-Director knew the resident I worked with since he was her colleague in training during that time....

the numbers that I gave you are just an average, as I recall them. I wasn't trying to insinuate that you had those numbers. My point remains that you should be able to understand how some people within the allopathic community would look differently upon DO's because of the admissions standards.

I'm oughta here for a long weekend so you guys take it easy!

Man this crud never ends on SDN.

VentdependenT said:

Man this crud never ends on SDN.

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Sad, but much of life is a pissing match. It's gonna go on as long as SDN does.

dc