Advice for a new intern?

[Foxxy Cleopatra]

Hi to everyone-

I'm wondering about what sort of things should interns be proficient in at the start of the year? I feel that my skills with tasks such as helping manage floor and unit patients is pretty consistent with other people interested in surgery at my level. However, I do not come from a very procedure-heavy program and am kind of afraid that I may be less experienced at some things in relation to my fellow interns. I've worked really hard at skills I can improve on my own like knot-tying and feel that I am probably up-to-par with other 4th years in terms of what we do in the OR.

The things I'm afraid of... for example, I have done a FEW chest tubes and lines, however, I emphasize the word few and I've never done anything like bronch someone on my own or perform a lap chole yet (some people I've met on the interview trail said they have had the opportunity to do these things.)

I work really hard and I feel that I learn fast, but I am afraid of technical inexperience now that residency is nearing. I actually planned to have this last 4 week rotation block as vacation and I was planning on hanging out in anesthesia and the unit because at my institution they are really great about letting students do lines. However, I had to have an emergent operation earlier in the year (I'm healed up and doing extremely well now) but I had to sit out one of my senior required rotations so now I am making it up (hence, very little time to hang out in anesthesia in the mornings.)

Any advice on things I could do between now and July that would be helpful in starting internship? I've been hanging out in the sun with my Marino's ICU book, which I actually find to be a reasonably easy read. Any help will be appreciated!

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[scutking]

Relax! Read War and Peace, or trek the Himalayas, or do something else you'll never have time to do for the next 5 years. You'll be exposed to nothing but surgery for the next 5 years, so take this time during the final months of your 4th year of med school to relax and simply enjoy life. Marino, and his buddies Sabiston and Schwartz, will still be there July 1.

 

[njbmd]

Originally posted by Foxxy Cleopatra
Hi to everyone-

I'm wondering about what sort of things should interns be proficient in at the start of the year? I feel that my skills with tasks such as helping manage floor and unit patients is pretty consistent with other people interested in surgery at my level. However, I do not come from a very procedure-heavy program and am kind of afraid that I may be less experienced at some things in relation to my fellow interns. I've worked really hard at skills I can improve on my own like knot-tying and feel that I am probably up-to-par with other 4th years in terms of what we do in the OR.

The things I'm afraid of... for example, I have done a FEW chest tubes and lines, however, I emphasize the word few and I've never done anything like bronch someone on my own or perform a lap chole yet (some people I've met on the interview trail said they have had the opportunity to do these things.)

I work really hard and I feel that I learn fast, but I am afraid of technical inexperience now that residency is nearing. I actually planned to have this last 4 week rotation block as vacation and I was planning on hanging out in anesthesia and the unit because at my institution they are really great about letting students do lines. However, I had to have an emergent operation earlier in the year (I'm healed up and doing extremely well now) but I had to sit out one of my senior required rotations so now I am making it up (hence, very little time to hang out in anesthesia in the mornings.)

Any advice on things I could do between now and July that would be helpful in starting internship? I've been hanging out in the sun with my Marino's ICU book, which I actually find to be a reasonably easy read. Any help will be appreciated!

Hi there,
You will never be asked to perform any procedure alone, that you are uncomfortable with. There will be a more senior resident to talk you through putting in chest tubes, central lines and the like. After doing a few rotations where I didn't get that much OR time, I even had to think about knot tying so relax and enjoy your time off. About two weeks into your internship, you are going to kick yourself if you don't.

As an intern, ask the more senior residents to let you watch them perform procedures. I bugged the anesthesia residents to let me put in Swans and central lines as they start cases. Most are happy to accomodate you. Try to get a month in the SICU where you will be doing plenty of line and the like.

You should have an idea of how to work up things like RUQ pain, acute abdominal pain and the like. You are going to learn to handle disasters in ATLS so don't worry about that stuff. No resident was born knowing how to manage patients. We are all learning. Your chief is going to give you the guidelines of patient management.

Learn to be detail oriented and write everything down on morning rounds. You main tasks will be to follow-up on everything that has to be done for your patients. What did that culture grow out? What are the results of that AM chest film? Hunt down the radiologists and get readings on all radiographic studies early in the day. Set up consults early and call the consulting team. Speak to the consults personally after they have seen your patients.

Keep the medical students organized and be very nice to the nurses. I can't tell you have valuable it is to go to the nurse after AM rounds at tell them the plan for the day for Mr. So and So. If you do that, they will make sure that your orders get carried out. Check out every lab test and replace electrolytes promptly. Make walkrounds in the afternoons and speak with families. Know how to do a good signout sheet. Put stuff on there that you would want to know if you were covering for the night.

Answer every page promptly and try to help if you can. The right decision always involves getting up and seeing the patient rather than trying to fix something over the phone. If a patient is crashing, load the boat (call the chief resident early rather than later), have fresh vital signs (even if you have to take them yourself) and have a plan even if it is not correct. Before you go to bed, check on and write a post op note on all fresh post-op patients. Look at all wounds on any post op patient that has a fever before you attribute the fever to atelectasis. If you are cross-cover, write a note and explain what you found and what you did. [" Called to evaluate patient in respiratory distress by night nurse. Pt seen and examined etc..."]

Ask plenty of questions and get into the OR every time that you can. Don't expect too much operating time as an intern. You main job is to learn good patient care. Go to the clinic with a smile on your face and help the team even if your fellow interns slack off. Be nice to the nurses. BE NICE to the nurses. BE NICE TO THE NURSES! They can make your job hell. A good nurse is not going to call you for stupid stuff in the middle of the night so get up and see the patient. They will also help you make decisions about things but remember that you are the physician even though you are pretty new.

Finally, enjoy this year. It goes by much faster than you think. You will not have the luxury of not knowing things during your second year so use this year to get valuable experience. No one expects you to come in and start treating patients immediately. You will have plenty of time to learn and grow.

Also, if you find that you are hating life, better to hang on and do well during intern year. A good work ethic will get you further than having superior knowledge but poor work habits. Attending physicians will always look out for the good workers. You can always find something different after internship if you do a good job. If you screw up during internship, you are going to have a difficult time and second year is going to be tougher because everyone knows you screwed up.

Don't let your fellow interns psyche you out. They are just as green as you are and all of you are in the same boat. Let the braggers go and keep taking good care of your patients. You really will learn on the job!

njbmd

 

[apma77]

Having done a surgery intern yr,,my advice..bow ur head down,,,work like a dog and dopnt expect to read ..u wont have a life or time to read!

 

[bonecutter]

Originally posted by apma77
Having done a surgery intern yr,,my advice..bow ur head down,,,work like a dog and dopnt expect to read ..u wont have a life or time to read!

Pay no attention to Apma77. His posts have the feel of a sorry old has been who couldn't hack it and is now determined to inflict his bitterness on the world at large.

I had many of the same questions and the overwhelming response I have gotten is to relax. Have some fun before you start. The learning curve of the intern is apparently pretty steep and the best way to prepare is to be rested and ready to go from day one. Good luck!

Bonecutter

 

[hotbovie1]

I have sort of the opposite problem. I come from a very procedure heavy program, but I felt that our rotations are relatively weak on teaching us basic patient managment. I know how to bust out tons of notes in the am, and I can start lines, chest tubes, do bronchoscopy and sew/tie quite comfortably. ANd I've got plenty of trauma experience, so I feel pretty comfortable with getting a pt through the first few minutes of ATLS. However, when the nurses call me with whatever problems arise on floor pts, I fear I'll be totally clueless! (Nurse: "Mr Vascular post-op doesn't have a pulse". Me: "Duhhhh...")

However, our residents assure me that whatever the differences amonst incoming interns are on day one, we are all relatively equal after the first month. I certainly hope so!

Thanks, Natalie for taking time to give your valuable advice.

 

[apma77]

BOne cutter ,,you and the rest of the critics to my posts can kiss my A$$..if you dont like em dont read it

freedom of speech rules!

 

[bonecutter]

Originally posted by apma77
BOne cutter ,,you and the rest of the critics to my posts can kiss my A$$..if you dont like em dont read it

freedom of speech rules!

Yes freedom of speech rules but only when coupled with logic and discretion. As you mature you will begin to realize that restraint and respect (both for yourself and others) are the only things that will lend value to your viewpoints. Otherwise it's just like shouting into the wind.

Bonecutter

 

[scutking]

I think NJBMD's post summed it up perfectly. Probably the biggest 2 things that my fellow interns have gotten nailed for this year are 1) poor attitude and 2) laziness. When you get that 3am page that Mr. So-and-so has a problem, go see the patient. It may require you to get out of bed, but it's worth it. Just make every decision with the thought in the back of your mind of "how would my actions sound during M&M conference?" Imagine saying to your staff at M&M that you got a page for a problem, handled it over the phone, and the patient developed a major complication. Better to say you went and saw the patient, had no idea what to do, and called your upper level resident. Your lack of knowledge as an intern is easily forgivable if you work hard and accept your limitations. The purpose of the whole year is about learning good patient management.

 

[Foxxy Cleopatra]

Hi all-

njbmd, that was awesome advice- it will be appreciated by many of us out there. Thanks for taking the time to write it for us!

I agree with Bonecutter, scutking, and hotbovie1- have fun while we can and we'll probably fill in the gaps pretty quick once we're there. I think I'm doing well with the fun part so far- the suntan speaks for itself!

Apma77, I'm rather entertained by your unrestrained cynicism and was happy to see you left a comment special for me- LOL! Seriously man, good luck with anesthesia- hopefully you will like it a bit more than you did surgery...

I think I was going through the "I'm going to be a doctor in 2 weeks but I still don't feel like I learned enough" phase but you all are right- we'll be good to go as long as we work hard once we're there.

Good luck to my fellow new R1's!

-F.C.

 

[unregistered]

njbmd thanks for that awesome post.

apma77's posts on various forums here all have no value. He's just bitter about something and is blaming everyone but himself about it, so pay no attention.

 

[Winged Scapula]

I haven't much to add to the excellent advice already given herewith, so I'll just "ditto" a couple of items...

Relax. There will be a great deal of variation with regard to skills and knowledge base when you start. Some will be good at procedures, and others will not. I came from a program heavy on clinical assessment but light on procedures. With some practice I'm on par with most of my colleagues procedure-wise. It will even out in the end, especially if you recognize your weaknesses and exploit opportunities to strengthen them.

WRITE EVERYTHING DOWN. There will be so much information, often given in terms you don't understand that you cannot remember it all, especially when sleep deprived and over worked. Have a system for writing down daily chores/duties and then checking and rechecking until they are all done (or you have a reason why they are not).

When you order a test, FOLLOW-UP on it. Nothing irritates me more than to find out at the end of the day that a patient has an abnormal lab or imaging study and no one checked it or did anything about it. I made the SAME mistake as an intern and had hoped to spare my juniors the same pain, but I guess it takes experience to know how to avoid that pain. Therefore, if you order a stat CT Scan on a patient, call call call Rads until you have the results, or at least until you know when it will be done and then...find the test and its results. If you are in a program where most of the floor work falls to the intern, don't expect the nurses to call you with all abnormal things, when something IS or ISN'T DONE or to notify the Chief. It is much better to have multiple people following up on things (or at least someone designated to do so) than no one.

Run the list over and over with your colleages. Especially if its a chore filled day. Meet with your fellow interns and juniors on service and make sure that all the duties from morning rounds are being done - check in with the Chief and keep him/her updated on things, especially with critically ill patients who are unstable. It may seem tiresome but things are less likely to fall through the cracks if they are addressed multiple times during the day.

As noted above, answer your pages - courteously and timely. Nurses can be your friends and if they believe you are not attentive to your needs, you will likely be more harassed than if you were. I honestly believe that I get more sleep than some of my more brusque colleagues.

I have to run but all in all, everyone's suggestions are excellent!

 

[Skylizard]

Originally posted by Kimberli Cox
WRITE EVERYTHING DOWN. Have a system for writing down daily chores/duties and then checking and rechecking until they are all done (or you have a reason why they are not).

When you order a test, FOLLOW-UP on it...if you order a stat CT Scan on a patient, call call call Rads until you have the results, or at least until you know when it will be done and then...find the test and its results...Meet with your fellow interns and juniors on service and make sure that all the duties from morning rounds are being done - check in with the Chief and keep him/her updated on things, especially with critically ill patients who are unstable.

I am in complete agreement with Dr. KC. I come from a perspective having completed a GS preliminary now preparing to begin a categorical GS program. What I have seen is a good resident is not much different from a good attending. ALWAYS look at your studies. DO NOT wait for the report to "come up on the computer". It is a very poor excuse to say you didn't know there was free air on the belly film because the radiology report was not ready. NEVER order anything STAT unless you intend to see/read/evaluate it STAT. If you order something STAT, you are documenting a certain amount of legal liability. You can not defend being unaware of a bad lab you ordered STAT and didn't bother to follow up on it for 6 hours! It begs the question, "why did you order it STAT?". A prime example is when someone orders a 12 lead EKG/ECG stat or otherwise. This is a study you absolutely must wait for and review immediately. Your role is integral in ensuring patient safety and post-operative care. Tracking labs and studies may not be as fun as being in the OR but failure to do so may kill someone and doing a good job will save at least one life in your first month of internship. I know for a fact that at Penn State, Dr. KC & her peers have been asked by the attendings, "I don't care what the report says, have you seen the film?".

 

[Foxxy Cleopatra]

Thanks Kimberli and Skylizard- that was good advice.

It never occurred to me that there was a litiginous risk of ordering things STAT. We write it pretty casually here, not out of urgency for the patient, but just so that the order is more likely to be performed. Knowing that there are legal risks inovlved if the order is not followed up on STAT, I'll make sure that if I write it, I follow up on it urgently.

 

[apma77]

sky lizard..i dunno which FP program you were in but most interns cant rip apart their senior resident even if they are at fault

you need to get real boss!

 

[Celiac Plexus]

Um, since this is an "advice" thread, I'd just like to advise against "ripping" any residents during your intern year. LOL.


Actually, I don't think there is a need for "ripping" anyone at any stage. People do make mistakes.

 

[womansurg]

Originally posted by Skylizard
Clearly, I would never or at least unlikely challenge the junior or senior....though, I am sure there are exceptions and Dr. ** will likely be able to relate to a certain 2nd year... that almost every intern challenged and flogged until she cried...several times

This is pathologic, dear. You are virtuallly crowing about witnessing and participating in situations in which a person is humiliated, devalued and injured emotionally. There are many ways to elicit performance from people. Abuse and ostracisim is one way, yet has been shown to be not very effective, and also to impair the exchange of honest information and negatively impact the overall learning environment.

I doubt your senior would be very inclined to positively affirm these experiences. They reflect poorly on your institution.

edited

 

[Skylizard]

Originally posted by womansurg
This is pathologic, dear. You are virtuallly crowing about witnessing and participating in situations in which a person is humiliated, devalued and injured emotionally. There are many ways to elicit performance from people. Abuse and ostracisim is one way, yet has been shown to be not very effective, and also to impair the exchange of honest information and negatively impact the overall learning environment.

I doubt your senior would be very inclined to positively affirm these experiences. They reflect poorly on your institution.

While I was trying to recall in a humerous way some very unpleasant experiences all the interns endured under a certain "pathologic" 2nd year and our ability to stand-up against the individual, it is lost on those outside of the inner circle of events. The reality was that almost every intern had a run in with this pathologic 2nd year and if they stood up to this resident and her extreme malignant and innappropriate behavior, she invariably broke down and cried. From an outside general perspective I agree with your assessment. Your point is well taken. It was poor judgement on my part to attempt to place a positive spin and/or interject this experience in this thread. My apologies. Unfortunately, I would add, my poor judgement has reflected most poorly on me and NOT any institution. I appreciate your fair comment womansurg.


As I have been reminded by a certain surgeon recently:
__________________
Patience is a virtue. Virtues are strengthened - like muscles - by exercise. When you ask God for patience, he doesn't give you patience - he gives you plenty of situations in which you can exercise patience.