Anxious about starting residency. Never wrote an order or script before, tips?

[Clark Kant]

---

Members do not see this ad.

Hi, Thanks to hard work and the advice I got on this forum, i was able to get into a great Psych residency. Thank you all, especially aProgDirector. 😀

I'm not worried about Psych, I love the speciality and read up a lot about it. But the four month Internal Medicine during Intern year scares me.

IM is a weakness, and by far my toughest rotation in med school. I'm not good at reading ECGs, or hearing murmurs.

I never wrote an order on the chart before, never ordered labs, don't know how to dose meds, how to replete sodium, potassium, magnesium, don't know how to run a code, or dose insulin etc. The idea of running a code, or doing complicated procedures scare me.

I am not a fast learner, it takes me a lot of time and effort to master things. Do you guys have any advice?

Are there any books that you found really helpful for this stuff, especially in terms of dosing meds and ordering labs and what not?

I bought Washington Manual and the Massachetusus Handbook but found the info in the latter really hard to follow (too many abbreviations).

 

[ShyRem]

A simple search will reveal some very nice concise resources. Some online, some in print. As for what you need, that is up to you. I would rather do a google search for "intern survival guide" and see what comes up.

Other than that, hopefully your senior residents will help you out. I too felt woefully unprepared for internship and residency. Now heading into my second year, I am comfortable as an intern, which apparently means I have to now be uncomfortable again. The push is good.... makes you learn. Lots.

And if it makes you feel better, I think it was the fourth day of internship I was cross-covering the ICU with the chief resident. I needed to replace some simple electrolyte and I recall looking at him and asking "how can I write for that? Is it PO? IV? PR? Holy crap, how much do I write for?" I think I asked four times where the nearest bathroom was. We all start ignorant and learn. 🙂 They expect you to ask and don't expect much more than to know your limits as a new intern and be able to write an H&P.

 

[Clark Kant]

A simple search will reveal some very nice concise resources. Some online, some in print. As for what you need, that is up to you. I would rather do a google search for "intern survival guide" and see what comes up.

Other than that, hopefully your senior residents will help you out. I too felt woefully unprepared for internship and residency. Now heading into my second year, I am comfortable as an intern, which apparently means I have to now be uncomfortable again. The push is good.... makes you learn. Lots.

And if it makes you feel better, I think it was the fourth day of internship I was cross-covering the ICU with the chief resident. I needed to replace some simple electrolyte and I recall looking at him and asking "how can I write for that? Is it PO? IV? PR? Holy crap, how much do I write for?" I think I asked four times where the nearest bathroom was. We all start ignorant and learn. 🙂 They expect you to ask and don't expect much more than to know your limits as a new intern and be able to write an H&P.

Thank you for the advice. As for google searching for resources, I'm not sure which ones are actually helpful.

I figure some of the interns on this forum who are finishing up their first year would know which resources were invaluable for them when it comes to writing orders, dosing medications and such.

 

[Law2Doc]

Thank you for the advice. As for google searching for resources, I'm not sure which ones are actually helpful.

I figure some of the interns on this forum who are finishing up their first year would know which resources were invaluable for them when it comes to writing orders, dosing medications and such.

Two things get folks through intern year in terms of scripts: a good pharmacopeia (either Tarascons or Epocrates), and the phone number of the hospital pharmacy. Ie you aren't sure what options you have to replete phos, you call up the pharmacist. They are there all night, are often knowledgable, and you don't have to bother your senior resident with every little thing.

Other tips are to always check units and decimal points-- the pharmacists usually catch the glaring stuff, but you'd hate to give someone milligrams instead of micrograms of a med. And go slow with pain mede, sleep aids and anti-anxiety meds on the elderly. The nurses are not your friends here, as they just want quiet patients and would be happy if you just snowed everyone. You'd rather have them complaining than obtunded though.

 

[Clark Kant]

Thank you. That is good advice. I will be sure to add the hospital pharamacy to my phone's speed dial, alteast for the first few months.

 

[1viking]

As the chief resident, I don't expect the interns to know anything. I'm at their hip the entire first month. Your attitude would make me more comfortable next month, as you recognize your fallibility. The arrogant intern is the one that scares me.

 

[JustPlainBill]

As the chief resident, I don't expect the interns to know anything. I'm at their hip the entire first month. Your attitude would make me more comfortable next month, as you recognize your fallibility. The arrogant intern is the one that scares me.

Can you and/or ShyRem help me resolve this...it really bothers me...

So when I interviewed, I told the program and everyone I interviewed with that if I didn't know something I would say, "I don't know" rather than BS them or write for something and potentially hurt someone. They all said it was an admirable and desired quality. Never got to talk to the interns though. A few second going into third years were from my school and said the place was ok, good training, etc.

So I matched. We start and I get on IM my second month. My first senior was ok - both interns started with 4 patients each, then we worked up to 5. the next senior flat out said we should be carrying 7, have everything done by rounds, orders in, electrolytes repleted, consults called, period. No guidance, period. When I said I didn't know how to do some things (like replete electrolytes), I get slammed.

It's been that way every since. Other interns/2nd years/3rd years get away with not knowing something, I get hammered. I've tried to bring it up to my advisor and he throws a fit and tells me what happens to other people doesn't matter....

My last IM went better. However, I have a habit of deferring to my seniors and running my plans/actions/what I've done by them to keep them informed of what the hell their intern is doing. New onset mumur, ordered EKG and labs -> called the senior to let them know -> barked at for calling at 07:00 (rounds at 08:00).....

I'm asking fewer and fewer questions as the year wore on, keeping up with my clinic, asking for help on complicated patients and generally know when something is serious and I'm beyond my limits -> but I still get dressed down with bad evals when I say,"I need some help here, what do you think about this on this complex patient".....

It's really bothering me and making me hate medicine.....I'm seriously considering leaving after my first year when I'm license elgible and doing either acute care work or cash only. I'm really frustrated here....

 

[gutonc]

It's really bothering me and making me hate medicine.....I'm seriously considering leaving after my first year when I'm license elgible and doing either acute care work or cash only. I'm really frustrated here....

First off, this is a horrible idea. Do NOT do this.

Now, sorry about your crappy year. Have you sat down with your attendings and seniors to get feedback during each month? What did your PD say when you went to talk to him/her about your performance. I agree with your advisor that whatever happens to other people doesn't matter unless you're being held to a different standard, but that doesn't mean you shouldn't be getting feedback and advice from your supervisors.

Is the resident you had a bad time with early in the year just a total loudmouth d-bag (there's one or 40 in every program) who has badmouthed you to his/her colleagues and now you're stuck with a rep (deserved or not) that you can't do anything about?

Most importantly, have you been offered (and signed) a contract for next year? If so...F 'em. You'll be in charge-ish next year and your destiny will largely be in your own hands. Be a better person to your interns than that a-hole was to you and move on with your life.

Finally, it is likely that you do have some clinical/knowledge deficiencies, and that's OK...this is training and everybody does, even if they don't admit to it. But you need to figure out what they are (see above about talking to staff), own up to them and actively work to improve.

 

[JustPlainBill]

First off, this is a horrible idea. Do NOT do this.

Now, sorry about your crappy year. Have you sat down with your attendings and seniors to get feedback during each month? What did your PD say when you went to talk to him/her about your performance. I agree with your advisor that whatever happens to other people doesn't matter unless you're being held to a different standard, but that doesn't mean you shouldn't be getting feedback and advice from your supervisors.

Is the resident you had a bad time with early in the year just a total loudmouth d-bag (there's one or 40 in every program) who has badmouthed you to his/her colleagues and now you're stuck with a rep (deserved or not) that you can't do anything about?

Most importantly, have you been offered (and signed) a contract for next year? If so...F 'em. You'll be in charge-ish next year and your destiny will largely be in your own hands. Be a better person to your interns than that a-hole was to you and move on with your life.

Finally, it is likely that you do have some clinical/knowledge deficiencies, and that's OK...this is training and everybody does, even if they don't admit to it. But you need to figure out what they are (see above about talking to staff), own up to them and actively work to improve.

Different standard -- I think so. For example - I honestly record my hours and get smacked for being 'slow' but the program admin recently said at a resident's meeting that the residents could stop sandbagging their hours now that ACGME has changed the rules. Another instance -- I get smacked for not knowing, let's pick an example here, not knowing the dosage to give of albumin on day 1 and day 3 of a suspected SBP...segue 3 months later when I'm on service over holiday block...same attending, asks another intern about albumin and SBP...intern doesn't know the dosage and no repercussions.....That's just two of many....

Already signed my PGY2 contract.....

Working on my deficiencies as we speak....studying for Step 3 and working hard to increase my efficiency and weak areas....

PD had 'concerns' and said I'd be promoted but there were 'concerns' about my ability to function independently and be in a 2nd year role....

 

[Buzz Me]

Unfortunately I've always found that double standards and the "unfair" culture of medicine is just something we all have to learn to deal with. Happens all the time.

Not saying it's right, just preparing you for what's to come the rest of your career.

 

[marsupial]

Calling pharmacists--good idea.

Everything is IMAGE in residency. Throw your humble pie out the door.

You should try to rehabilitate your image.

1) Try to answer questions in lecture

2) Keep a serious demeanor

3) Make a list of which seniors you can ask these kinds of questions to safely

4) Stealthily check UpToDate for things you're not sure about, in lieu of looking bad by asking for help directly. You're getting burned.

 

[smq123]

So I matched. We start and I get on IM my second month. My first senior was ok - both interns started with 4 patients each, then we worked up to 5. the next senior flat out said we should be carrying 7, have everything done by rounds, orders in, electrolytes repleted, consults called, period. No guidance, period. When I said I didn't know how to do some things (like replete electrolytes), I get slammed.

It's been that way every since. Other interns/2nd years/3rd years get away with not knowing something, I get hammered. I've tried to bring it up to my advisor and he throws a fit and tells me what happens to other people doesn't matter....

My last IM went better. However, I have a habit of deferring to my seniors and running my plans/actions/what I've done by them to keep them informed of what the hell their intern is doing. New onset mumur, ordered EKG and labs -> called the senior to let them know -> barked at for calling at 07:00 (rounds at 08:00).....

I'm asking fewer and fewer questions as the year wore on, keeping up with my clinic, asking for help on complicated patients and generally know when something is serious and I'm beyond my limits -> but I still get dressed down with bad evals when I say,"I need some help here, what do you think about this on this complex patient".....

A few things -

- Simply saying "I don't know how to replete electrolytes" is not going to win you any fans. While I applaud you for being willing to admit what you don't know, you still need to offer to look it up. It's what I would expect an MS3 to say; I would expect the same from an intern.

Electrolyte repletion is not difficult. It is easy to find something on emedicine or UpToDate that explains how to do it. Hospital intranets often have a pharmacy "cheat sheet" that explain how to order K-riders, etc. Saying that you "don't know" how to replete electrolytes is a poor excuse, when it is such an easy thing to look up.

- Halfway through intern year, a new onset murmur in an otherwise hemodynamically stable patient is not something that you need to discuss with your senior over the phone at 7. You can bring up the fact that you heard it, ordered an EKG, will get an echo, etc., during rounds. While the senior might want to know about it NOW when you're a beginning intern, halfway through the year, it's no longer necessary.

- In a way, your advisor is kind of right in that what happens to the other interns doesn't matter. You may feel like you're being singled out, but it doesn't help the fact that you seem to have some deficiencies that your seniors are concerned about.

Another instance -- I get smacked for not knowing, let's pick an example here, not knowing the dosage to give of albumin on day 1 and day 3 of a suspected SBP...segue 3 months later when I'm on service over holiday block...same attending, asks another intern about albumin and SBP...intern doesn't know the dosage and no repercussions.....That's just two of many....

Medicine is all about first impressions. We all do it - from the first rapid evaluation of a patient when we walk through the door. We do the same to our interns and our students, whether or not that's "fair." The first impression that you made seems to be that you're unwilling to look things up by yourself or think things through by yourself, and that, in turn, has gotten you a reputation that you're "clingy" and dependent. It's hard to shake the first impression, but I wish you a lot of luck in doing so.

 

[Law2Doc]

A few things -

- Simply saying "I don't know how to replete electrolytes" is not going to win you any fans. While I applaud you for being willing to admit what you don't know, you still need to offer to look it up ...
- Halfway through intern year, a new onset murmur in an otherwise hemodynamically stable patient is not something that you need to discuss with your senior over the phone at 7. ... .

Agreed. One of the hardest things about intern year for some it taking that step where they come to the realization that they are no longer a med student there to pass along information to the seniors and blindly follow instructions, but instead are actually THE doctor to all these patients. The seniors are there to help out, particularly at the beginning, but honestly you shouldn't be annoying them with every little thing like electrolyte repletion. There are lots of sources you can look that up on, and as mentioned you can always call the pharmacists for help. Thatsvthe kind of thing most seniors don't want to micromanage, and just want to hear that it got done if they ask after the fact. There will definitely be times when you are over your head and need help. At all other times, you should first see if you can handle it/look it up before involving your senior.in terms of being someone willing to say "I don't know", you have to realize this is a virtue as compared to the dude who will make stuff up rather than admit he doesn't know the answer, but it is never better than actually knowing the answer or actually having at least made a good faith attempt to learn the answer from the resources available to you. At some point for most, a switch clicks on and interns start to function more or less independently. For others this comes later, and these folks suffer a lot of the issues the above poster described. Not all interns get treated equally because the prove themselves to not be equal. An intern who doesn't seem to "get it" will absolutely get more abuse and have his feet held to the flame a lot more than the guy who let's his seniors sleep while he minds the store at. Much earlier point in the year.

 

[dpmd]

Agree so much with calling the pharmacist. Nothing annoys me more than getting asked what dose of X I want by the intern when there is one typically given dose (when there are a few typical doses I cut them some slack). I carry a pharmacopeia still because I like to be able to check on stuff especially if I don't write for it often. The intern asking me without even attempting to look it up or ask the pharmacist just seems lazy to me. I still call the pharmacist sometimes (today I had to figure out what units the new computer system wanted for replacement for calcium chloride because we no longer have calcium gluconate).

As far as orders go, just make sure that you put in all the information that would be needed to carry out the order. Want an NG tube-you need to specify what you want done with it (place it to low intermittent suction). Want a medication-you need to specify the med along with dose, route, frequency. Same goes for prescriptions (plus you need to indicate the quantity you want dispense).

This is why schools that don't let their students do anything are such a problem. Intern year is hard enough without feeling like you don't even know how to do basic things (you know how to write a note I hope-I know some places don't let the students write in the charts, so I wonder how they learn how to write a note that isn't sh*tty). With the exception of running a code and "complicated procedures" I had done all the things you had listed as a student and still had my cheat sheets for electrolytes and stuff to work off of once I started internship. I feel bad for the students who are deprived of this kind of learning.

 

[tkim]

Two books - besides the Pharmacopeia that I leaned on a lot intern year:

The Scutmonkey Book:

http://www.amazon.com/gp/product/00..._m=ATVPDKIKX0DER&pf_rd_r=01MJ47NHFZ9QRN52Q968

Pocket Medicine:

http://www.amazon.com/Pocket-Medici...ndbook/dp/1608319059/ref=cm_cr_pr_product_top

Pocket Medicine you should already have. Scutmonkey you should get if you weren't properly scutted out during M3 and M4 years.

Scutmonkey will help you write notes, write scripts, and order/interpret labs. In other words - work. Pocket Medicine will make you look smart during rounds. In other words - grades.

 

[Clark Kant]

Two books - besides the Pharmacopeia that I leaned on a lot intern year:

The Scutmonkey Book:

http://www.amazon.com/gp/product/00..._m=ATVPDKIKX0DER&pf_rd_r=01MJ47NHFZ9QRN52Q968

Pocket Medicine:

http://www.amazon.com/Pocket-Medici...ndbook/dp/1608319059/ref=cm_cr_pr_product_top

Pocket Medicine you should already have. Scutmonkey you should get if you weren't properly scutted out during M3 and M4 years.

Scutmonkey will help you write notes, write scripts, and order/interpret labs. In other words - work. Pocket Medicine will make you look smart during rounds. In other words - grades.

Thank you. That's super helpful advice. I purchased both along with the 2011 scut monkey pharmacopedia aka. "Clinician's Drug Pocket Reference" (it has a lot more info on what the drugs actually do than tarascon's).

 

[Law2Doc]

?...(it has a lot more info on what the drugs actually do than tarascon's).

that's fine but careful with the "lot more info" part; sometimes as an intern, less is more. You don't want there to be too much info on what the meds actually do in your pharmacopeia, just the class of drugs, dose and major interactions/ contraindications. The goal is something small and easy/quick to use. You really want the Cliff Notes version of everything while on call. Much as attendings will tell you otherwise, you don't have all that much time to read during intern year. During rounds it may be enlightening to talk about how these drugs work, but late at night when your pager is going off, you don't want as much to sift through.