1. Write everything down. I put little open boxes and then write down tasks under each patient's name as I am being told them or as I formulate them myself. I check, check and triple check that everything is has been done, including any labs, cultures, imaging, consults and/or procedures. Be obsessive compulsive about it. You can never check too many times.
2. Call consults early. Break off rounds, if need be, to page them so that stuff gets done today. Schedule imaging tests during rounds and whatever else needs to get done. During medicine rounds (eternal rounds) there can be plenty of pontificating other the intern's patients that doesn't matter that much in the grand scheme of things. Use this time to get stuff done or fill in your notes about your own patients. Otherwise you are snoozing.
3. If you are not sure about something ask the higher ups, pgy2/3s. They've probably been through it before.
4. Keep higher ups in the loop. Run "list" (of your patients) as frequently as necessary. If there's any sign of trouble make sure pgy2/3 knows about it early.
5. Don't piss of the nurses, but learn to set limits with them. Especially if you are busy and cannot see the patient right away, unless it's an emergency. However, be nice to them, smile and compliment them.
6. Let the nurses know about your game plan and why. This especially important since sometimes you may not been able to come up and explain something to the patient within any reasonable time It can save a lot of anxiety for the patient and the nursing staff. Get to know the great nurses from the average to the dangerous.
7. *Always see the patient if the nurse calls you about it.* That includes mini hpi, current vitals, pertinent physical exam, lab and meds review. This is especially true in the middle of the night.
8. Start thinking about how you can discharge the patient from the day they are admitted. Get case workers/social workers involved early. Get the physical therapist on board from day one.
9. Some daily thoughts. what is the patient's daily weight, I/Os? When was the last bowel movement? Are they on a bowel regimine and if not why not? Can I convert anything from iv to PO? N/V/D? Pain? Fever? Does the patient still need IV fluids any more? Is my patient getting up and walking around or do they need dvt prophylaxis? Laying in bed all day? Get Incentive spirometry and PT to see them.
10. Discuss DNR/ code status early with your patients. If they agree to DNR, document it and get your attending to document it with in a reasonable amount of time (<24hrs).
11. At night spend 30 minutes writing skeleton outline progress notes on your patients and then fill in the blanks as you go on rounds.
12. Have a game plan, in terms of imaging, blood work, abx, ivf, etc ready... ie contine this or that, r/o this or that with this test(s), and start such and such medicine or this pt needs procedure x for y. Lastly, the hospital can be a dangerous place for patients. If you even think that the patient may go home "soon", stick that in your game plan. Tell your attending that I think if x and y comes back wnl, then we can discharge the patient this afternoon or tomorrow morning.
13. Even though you will try to help everyone,t you will still have patient who for whatever reason willl not make it. You have to learn to deal with the reality and limitations of medicine. This is one of the most difficult aspects of going from medical student to intern.
14. Don't expect the ER to fully work up your patient for you. Realize the limitations on ER attendings' time and other political forces that may be at work. Admitting/discharging a pt is not in your hands. Just do the admission and get on with your life. (Hit me with your best shot, fire away).
15. Some consult services will try to weasle out of seeing the patient. Don't let that happen, let them know you will be documenting the conversation (ie, that you called the consult and with whom you spoke to). The consult may not like you and your patient may not know it, but your patient should thank you for having the right people in the loop. Know why your are calling the consult and in particular what question(s)/procedure(s) you need answered/done.
Probably one of the most guilty job of internship was calling in bs consults that my attendings wanted me to call. Make sure they actully do see the pt because sometimes there is no convincing an attending that it's not necessary. Some docs just love CYA medicine. Sometimes you may be able to present a patient in such a light as to sway your attending one way or another in terms of calling the bs consult or not. It's all a matter of presentation baby.
15. Just remember to smile because this is only one year and your future is bright. Anytime someone, patient, nurse, attending yells at you, just smile at them with a big wide grin. Cause you are mentally reminding yourself where you'll be going at the end of internship year.
That cheered me up immensely whenever things got ugly. People around the hospital wonder why I smile so much, but I know why.
16. There are probably others, and I'll try to post them when I get a chance.
