tips for a soon to be intern?

Regardless of how much it hurts sometimes, be friendly with the nurses. If they like you, your life will be better (although there are posters here that vehemently disagree with sucking up to the nursing staff).

Anyway, your days will be happier if you are nice to them.

To build upon what others have already said about knowing the systems and getting along with nurses: ask the nurses to help you navigate the system. We know a lot of that stuff inside and out because we don't rotate hospitals, and rarely float between units. Before you hand-write a complicated order set, ask a nurse if there are pre-printed sets. It will save you a ton of time (not to mention aggravation when something gets missed because you're human and then the nurse has to call).

Tired said:

4 patients . . . Believe me, you'll get much better.

I think the big secret about internship is that you really don't need medical knowledge. You need to learn the systems. The quicker you figure out how to get stat labs done, how to get that CT scan ordered, who to talk to about following up cultures, etc, the better you'll do (and the less stress you'll have in your life).

A trained monkey could be a good intern.

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yep.

the systems/culture that tired is referring to is key. it can be easy to know that you need a stat ekg, troponin, in a patient with a a high risk of cardiac disease... it's a whole different thing to get it done. what i tell my interns is that at many times, the medicine seems easy, it's getting it done that's the hard part. unfortunately, there are many people in the medical system that are involved in the care of the patient that aren't necessarily invested in the quality or timeliness of the care patient.
so, while you want that stat ekg, the ekg tech might be on his/her smoking break, or about to get off shift, etc. etc.
while you might want to get a a blood culture right now, it might happen to be 445, and the phlebotomist gets off at 5 and figures it will take him/her 15 minutes to get there.
knowing who to call when you're in a pinch can, at times, be the difference between providing great care for your patient, and just skating by.

also, learn the names of the techs/phlebotomists/cafeteria lady, etc. you may find that you can get a stat chest x ray, ultrasound, stat labs, or hot food after the grill is closed when others can't. i'm not saying to learn all of their names, but at least if they feel like you know, and they feel that you're nice, it can make things a lot easier for you.

Tired said:

The difficulty I have with this advice is that not all nurses are created equal. Some give you great advice, others give you terrible advice. It is hard enough to tell your Chief, "I did the wrong thing." It is much harder to say, "I did the wrong thing because the nurse told me to." I 've been there. It sucks.

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fortunately/unfortunately, part of internship is also learning which nurses are reliable and trustworthy, and which ones aren't. depending on the size of the hospital and stability of the staff, this may be rather easy and straightforward, or near impossible!

Tired said:

The difficulty I have with this advice is that not all nurses are created equal. Some give you great advice, others give you terrible advice. It is hard enough to tell your Chief, "I did the wrong thing." It is much harder to say, "I did the wrong thing because the nurse told me to." I 've been there. It sucks.

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ditto.

One of the smartest things I ever did as an intern was to find out where the dictation steno pool office was. I brought a batch of lemon bars to thank them for processing my dictations so efficiently. For the rest of the year my dictations were sped through the system. They never had been personally thanked before, by any doctor. It was magical.

Years later, my wife was on the tennis court and mentioned that her husband was a doctor. Knowing my wife's last name, one of the other players said "did your husband bring lemon bars to the typing pool once?" More than 15 years later they still talk about it.

Heh...

While I am not opposed to taking in lemon bars or any other sort of treat to the transcriptionists, the ones we have now are so awful that they don't deserve anything. I spend more time correcting their spelling mistakes than it would take me to just type the darn thing myself.

The ones we had for residency WERE good though.

And people wonder why sometime nurse's don't bother reading the doctor's progress notes? I have a hard enough time reading their orders. For some reason at my facility, the nursing notes and assessment charting is all computerized...but the physician's isn't. so they can either write their notes or dictate. There is one surgeon that I wish would just dictate, noone can read his handwriting, sometimes he can't read his own handwriting, but he refuses to dictate.

There is one doc who has such bad handwriting that I offer to let him dictate to me even when he is present. On some level I cringe because I realize that's re-visiting the subservient role, but it beats the alternative. I spend less time writing for him than I would trying to figure out what in the world he wants done.

Tired said:

The difficulty I have with this advice is that not all nurses are created equal. Some give you great advice, others give you terrible advice.

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I can certainly understand this. I was thinking more along the lines of "is there an order set or protocol for a diltiazem drip? Where can I find it?" Like you said, learning the systems is a crucial piece and nurses are generally familiar with stuff like that (or at least they should be ).

Here are some tips for writing orders that will (hopefully) result in fewer phone calls. I make no promises.

For initial orders, make sure the highlights are addressed:
Admission order: specify inpatient, observation, or bedded outpatient; specify diagnosis; specify attending physician
Code status, frequency of vital signs, diet order, activity, running or capped IV, oxygen to keep SaO2 >92% (or whatever--obviously this varies based on the patient)
When requesting a consult, specify reason
When ordering radiology tests, specify reason
Write parameters for calling you (i.e. call MD for temp > 100.5)
Write for prn meds: Everybody needs Tylenol. Even if they're not there for anything pain related. Unless they're NPO or in liver failure, they all need Tylenol because they will invariably get a mild headache or back ache from the lights and the bed or whatever. Elderly people and anyone on narcotics will probably need something for constipation: Colace bid is great, with options of MoM, Dulcolax, and Fleets if needed. Tums are also nice.

Thing that JCAHO is currently emphasizing:
Limit range orders. It seems that small ranges of the dose are okay, but no ranges for times. Also, they want the reason for the med. So for example:
Morphine IV 2-4 mg q 2 hrs prn pain
Vicodin 5/500 1-2 tabs po q 6 hrs prn pain

Farmer Jane said:

Thing that JCAHO is currently emphasizing:
Limit range orders. It seems that small ranges of the dose are okay, but no ranges for times. Also, they want the reason for the med. So for example:
Morphine IV 2-4 mg q 2 hrs prn pain
Vicodin 5/500 1-2 tabs po q 6 hrs prn pain

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Does JCAHO say to limit ranges or eliminate them?

I've had some hospitals refuse to accept orders which include ranges. So...

Morphine 2 mg IV every 2 hr prn mild pain
Morphine 4 mg IV every 2 hr prn mod pain
Morphine 6 mg IV every 2 hr prn severe pain and call HO...etc.

its a real pain.

From what I understand, eliminating ranges is the ultimate goal (and the ideal in their eyes is to write things just as you did) but that the first step was to eliminate time ranges, then to narrow dose ranges, so where I work at least dose ranges are still acceptable. Who knows when and where that will change.

I swear JCAHO is part of a conspiracy to decrease the efficiency of healthcare.

It's the double ended range orders that they don't like (morphine 2-4 q 4-6)

Winged Scapula said:

Does JCAHO say to limit ranges or eliminate them?

I've had some hospitals refuse to accept orders which include ranges. So...

Morphine 2 mg IV every 2 hr prn mild pain
Morphine 4 mg IV every 2 hr prn mod pain
Morphine 6 mg IV every 2 hr prn severe pain and call HO...etc.

its a real pain.

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And on the 8th day, God created the PCA.

They are wonderful things.

I've seen nurses do that too.

*bangs head against wall*



More on writing orders. For whatever reason, there is always confusion about which orders to follow on the day of surgery. I would recommend writing:
"On 2/25/08 in am
give Lovenox dose SC
Lantus insulin dose SC
D5 0.45% NS c 20 mEq KCl at 125 cc/hr

or whatever. It may save you 1) a phone call 2) an important medication being missed because someone thought that baseline insulin or whatever else should not be given on the morning or surgery.

I realize this will not prevent all issues, just trying to give ideas to lessen confusion on the issues I see the most.

Here is some advice for you - GET AS MUCH SLEEP AS POSSIBLE while you still can!

No matter how much people tell you intern year is exhausting, you just can't understand it until you get there.

Bend Over Here It Comes!

A friend of mine who is just finishing his EM residency, talked to me at church today. He said "Well... are you getting ready for it? My advice is do everything now that you have wanted to do that has nothing to do with medicine. Don't worry too much about studying and preparing. My first week of residency there were all the nerds (his words) that had been studying for months and reading all the books. It made no difference. You are so far behind the learning curve and its such a steep learning slope, spend your last free time doing everything you wanted to do that is not related to medicine".

Doowai said:

A friend of mine who is just finishing his EM residency, talked to me at church today. He said "Well... are you getting ready for it? My advice is do everything now that you have wanted to do that has nothing to do with medicine. Don't worry too much about studying and preparing. My first week of residency there were all the nerds (his words) that had been studying for months and reading all the books. It made no difference. You are so far behind the learning curve and its such a steep learning slope, spend your last free time doing everything you wanted to do that is not related to medicine".

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...puts his Step 3 book down...

group_theory said:

If you are going to do something that is not "routine", give the nurse a heads up (and sometimes a reason)

ie ... the patient is to received his full insulin dosing regiment even though he will be NPO after midnight

when you tell the nurse your reasoning, you can also ask that he/she pass it along on report ... hopefully it will save your colleagues a call at night or the next day

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Thanks for including the nurse in the equation...

Though, 3x in this last week, your pt, who received received his "normal" SS insulin (R)(home regimen, carefully thought out by the FP doc), @ 2100, and was NPO after MN (thanks ED doc) crashed at 0800, and surgery had to be rescheduled d/t "confusion regarding his home meds," though the (lowly) RN pointed this out to you, and you said "I'm asleep, tell the day doc"

Yea, we're the incompetent one...

True story...



I agree w/ your sentiment: many nurses don't get "it"

But do what many of your colleagues do:
Do all of your corresponding (with nursing) via progress notes...

after all, the nurses SHOULD know what you mean, riiight??

signed,

any angry resident who wishes (s)he would have majored in business, and biiiitch about it to anyone who'll listen on SDN...

Getting back to something the OP mentioned.... the time it takes to see patients on pre-rounds. I don't know how the interns do it, I mean, I get in with 3 hours to pre-round and I barely finish 6 patients. I get all my labs at one computer, I go to their rooms in an organized route through the hospital. Even still, it takes me forever and there are always hold ups (somebody else has the chart, there was a consult that I can't read, an order didn't go through, the patient is in CT and I have to come back, blah blah blah). The thing that takes me the longest BY FAR is seeing the actual patient. They all want/need 20 minutes of Q and A (and God FORBID they have a family member in the room) and I feel terrible being rude to them b/c I'm in such a hurry, but I have no choice.... so THEN when I come back later with time to spend with them, they have no more questions.
It's really frustrating and I don't know how I'm gonna get thru 12 patients in the morning in time for rounds w/o showing up at 2 am. Any help/advice would be appreciated!
Thanks in advance

..Get a system of organization that works for you...and get it fast-interns are about GETTING THINGS DONE....not learning quite so much...if it happens great...but 9 times out of 10 the resident/ attending is going to want to know if Mr./Ms. Such And Such got that CT with contrast/MRI with gad..and oh yeah...have all three of the AFBs come back negative so we can discharge Mr. X ? -what do you mean you didn't know that you needed to request INDUCED sputum cultures??...have you spoken to social work about re-instating the patient's home health services tomorrow ? Oh wait-now the family is requesting 24 hour daily care rather than the 5 that the patient came in with-guess the patient will be staying another day...

I promise you that the following will be helpful to you

1. Find out if the patient has home health aides/visiting nurse services when you first encounter them-then you can speak to social work about what the needs are to anticipate d/c

2. Start the d/c summary soon after the patient has been admitted-it's tough to do this while on call-but I recommend it highly post call-the WORST is trying to discharge 5-6 patients and trying to get every day work done without nary a d/c summary or prescriptions written or follow up appointments made

3. Order 3 AM labs when possible-you will have your results in time for rounds and be able to finish notes quickly

4. Write pre-fab SOAP notes prior to seeing your patients-for instance: I get a progress note for all 12 of my patients and fill out a skeletal note for each-I leave the " S" blank with space to fill in ( o/n events and such ) ; " O " with vital signs from the morning, blank PE, filled in lab values ( hence the 3 AM labs ), and pre-fill in the A/P with addendums as needed based on how the needs/plan of management might change after we have discussed the patient-I NEVER have notes in my hands after attending rounds-NEVER-makes a HUGE difference in my time

5.CALL CONSULTS EARLY-even while you are in attending rounds if possible-I've never had an attending who particularly minded this as long as I was not presenting

6.Call all depts for the studies you have requested EARLY to NICELY inquire as to what time can Mr./Ms. Such and Such be sent down to get that echo/ct/ sono whatever...

7. Make nice with nurses-especially the ICU ones-they know their stuff and can be your best friend or worst nightmare-choose the former.

I have found that the above have helped me tremendously with easing my year-especially with respect to time-I am always ready to sign out way before the assigned time ( that's a whole other issue specific to my prelim program) whereas other interns are leaving at 7 PM or later.

PM me if you have other questions.

divinemsm said:

.
2. Start the d/c summary soon after the patient has been admitted-it's tough to do this while on call-but I recommend it highly post call-the WORST is trying to discharge 5-6 patients and trying to get every day work done without nary a d/c summary or prescriptions written or follow up appointments made

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Good advice.

3. Order 3 AM labs when possible-you will have your results in time for rounds and be able to finish notes quickly

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Depends on the hospital. Some do not have 24 hr phlebotomy and either you or the nurses will have to draw it. Okay in an ICU, but I find that many floor nurses are less than interested in waking patients to do it. But see what your local hospital policy is (and is otherwise good advice to specify an early time so they are back before rounds; otherwise an "am" order will be put off by the 11p-7a nursing team until after they sign out).

5.CALL CONSULTS EARLY-even while you are in attending rounds if possible-I've never had an attending who particularly minded this as long as I was not presenting

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Agreed. There is almost always some dawdling or repetition of plan to the patient, so as soon as you hear "let's consult X", dash out of the room, go the phone and page "consult team X". We had lots of hallway phones so I could slide out of the room while the team was saying their goodbyes to the patient and get the consult ordered. Check!