Becoming an Organized and Efficient Intern

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igotmyswag

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I was just wondering if anyone could offer any suggestions to becoming an organized/efficient intern? I have a problem with being a bit unorganized in general and I was wondering if anyone had a particular method/procedure that they follow that tends to serve as a good template? I am open to any ideas that I can mend into my own plan; but I am trying to have my $h!t together for internship. The last thing I want to be is the unprepared intern or worse the one who stays until 10pm every night!
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sometimes staying late can be the best thing-> shows grat dedication
 
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No, staying late just gets you in trouble because the programs are just paranoid about getting accused of any work hours violations. Also, staying late can get you accused of being disorganized :)

One thing that helps is to make yourself a checklist on rounds, of all the things you need to do for each patient. Then as you do them (i.e. call a consult, order certain labs, etc.) you check off the little box. Repeat until you've done everything on your list.

You have to find some system to organize your data too (labs, etc.). Everyone does this differently. I've seen people use index cards (I always found them too small, though) or those spiral-bound index card/notebook thingies, etc. As noted above, there are resources you can download also.

Sometimes you can skeletonize your notes for the next a.m. the night before, particularly when you are on call, have to be there in house any way and know you will be pressed for time rounding in the a.m.
 
You may find your particular program has a way their interns are expected to be organized. For example, one of my friends from medical school used to organize himself using index cards, but had to scrap that method when he arrived for internship because they use a shared patient list. Other places use a "Book of clinical opportunity" where each patient has a page listing clinical info and a scut sheet, etc.

Just don't get too freaked out prior to starting. Your first week, you may wind up staying late because you don't know how to get things done, or what order to do them in. As you develop, you will learn the way your program expects things to be done.

A couple of vague tips that may make sense as you go through this process: (1) get orders in first and get your notes on the charts if you haven't already -- if you don't you're going to start getting called by nurses, and answering them will take more time than just having put the orders in; (2) call consults next -- this will let your consultants start their work, and give them ample time to see your patient and make recs prior to p.m. rounds; (3) do procedures and other things that require you to be at the patient bedside. If you ever have a few minutes of "down time", where you don't know what you should be doing because you're waiting for results, etc. go through your list and make sure there's nothing you can't be doing right now -- getting skeleton orders ready for a pre-admit, updating your list, eating lunch, etc. (4) if you don't preround, write as much of your note as you can while rounding so you don't have to do it later.

Best,
Anka
 
agree with anka about getting all the orders in either during rounds or right after.
Then, call your consults right away (or even during rounds, if possible).
The importance of these two makes it important to try to get your notes written and in the chart before rounds, if you can. Or at least have most of them done.

p.s. I thought most all interns prerounded? If you don't, I'm confused about how you'd present the patients or when you'd get the notes written?
 
Prerounding is program dependent (and within programs may be site/rotation dependent). On our services, we don't generally preround. The notes are started by the call person from the night before, who writes in the vitals and the overnight events. As we round, someone performs a brief physical exam and calls out the results, which someone writes onto the notes. The chief dictates the plan. If there is a cross cover the night before, it is often prudent to come in a little bit early and scope things out (e.g., listen to the lungs on the patient we're worried about their pulmonary status) and enter orders when there is a plan from the night before or a pathway (or your chief won't mind the type of order you're putting in). If you are able to multi task a bit (or if there are two interns), it's pretty easy to write the notes as you go while at the same time keeping your list up to date. Then get the notes on the chart before you start putting in orders, calling consults.

Later on in the day, the interns are expected to round on each patient as they are going about their daily tasks to give them a full evaluation.

Best,
Anka
 
another tip, the second you write the order for discharge is the same second you pick up the phone to dictate. if you learn this rule and live by it, your internship will run much more smoothly. you'll remember the salient points of the admission, need to look through the chart less, be more accurate, and you won't have charts hanging over your head with medical records paging you every day.
 
DOctorJay said:
another tip, the second you write the order for discharge is the same second you pick up the phone to dictate. if you learn this rule and live by it, your internship will run much more smoothly. you'll remember the salient points of the admission, need to look through the chart less, be more accurate, and you won't have charts hanging over your head with medical records paging you every day.
Click to expand...

This is excellent advice. Getting called by medical records to dictate some patient you discharged months ago is so painful. It takes 10x as long to dictate, not including the time it takes to look everything up again.
 
Although my methods are still in flux (only 3 wks left though), I'd say in general, have a system and stick with it. If you use scut sheets, use the same ones. I also make a separate to do scut during rounds and put it either on my sign out or on a separate sheet of paper. This helps because I get the important "to do" things covered early. Also, I tend to call consults first, put in important orders next, and schedule studies next. I'm at the VA, so if you don't get a spot in the scanner early...you can kiss it. Also, the computer system makes it somewhat streamlined. For me notes come as a later priority, but computer makes it much easier. Anyway, I'd say not to stress out. You will find what is best for you. Biggest thing is to give yourself enough time to see ppl on prerounds when you first start.
 
This is all great advice.

Here are a couple more...

  1. Have a system and stick with it. Tweak it as you go, but, in general, don't scrap it altogether and start over.
  2. Some things are better done by others. This only works if you know others' jobs, and if you have good rapport with them. For example, you can ask secretaries to fax med records requests or ask social workers to find out the PT/OT recommendations on discharge planning, etc.
  3. Prioritize which patients you see in which order... See the sickest first, the ones going home next, and then everyone else. If you see the sickest first, you can get consults, blood work, and tests "cooking" while you're working on other things.
  4. See the tip from DOctorJay above... ultra important.
  5. Have stuff pre-done for you... If you're going to do a procedure, write an order for the tray/equipment/#7 gloves to be placed at the bedside and for you to be notified when the patient is ready.
  6. Instead of checking again and again for test results... include "notify me when completed, pager #wxyz" to your order. Then you're not looking up chest Xrays that aren't there.
  7. Write your notes away from high-traffic areas... otherwise, you'll get nickeled-and-dimed. If you're standing near the nurse's station, you'll get sucked into conversations, asked for directions, asked for pager numbers, etc. I'm not saying don't be helpful. I'm just saying, there's a time to be helpful and there's a time to buckle down and bang out your work. Every interruption takes a time to recover from (and is an opportunity for an error, by the way).
  8. Ask... Just like Anka mentioned that prerounding may be program dependent... so too with everything else. The type of rounds, the computer programs, the floor layout, etc - all program-dependent. So, find out who the most neurotic organization-freak is in your hospital and ask them... especially if it is an attending. (And don't worry about exposing your weakness to that attending by asking... it's actually quite the opposite... by asking and prefacing with something like, "Everyone says you're the most organized person in the hospital. Well, I was wondering if one day when you have 10 minutes or so, if you could go over some pointers with me."... you do that and (a) you get the tips you need, (b) you've invoked an important element in persuasion (not enough room to explain here, but, in short, they're more likely to comply with your request and more likely to look upon you favorably), and (c) you're probably asking the person about something they're passionate about so they'll be more than happy to help.
I hope this helps

Dr. Tori
Follow me on Twitter: http://twitter.com/RookieDoc
 
If you have an iphone, I may have an app that will help you.

I hate keeping up with notecards and pieces of paper, so my husband and brother are in the process of creating an iphone app that will basically do the samething as a notecard. If you are interested in getting it for free and helping beta test it, PM me. It should be ready within the next 2 weeks. (there are a couple others on the market, but they don't fit my specification...ie are too slow or have too much typing required)

Becky
 
I just wanted to thank everyone for this post. It is really helpful.
 
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I agree with the idea of keeping a checklist. Keep a list of your patients, and make sure you write down, with checkboxes, what tests need to be followed that day, what studies/labs needed to be ordered, what consults need to be ordered/followed, and any plans for discharge.

I would also suggest that if you anticipate any discharges on a particular day, get all the discharge paperwork done early, including discharge instructions and prescriptions.. That way, once the attending agrees with you that the patient is ready for discharge, all you have to do is write the discharge order and sign it. This is especially when you send a patient back to a nursing home. If you can get the paperwork done early for a patient going to rehab or a nursing home, case management/social work has more time to make the arrangements, and hopefully you can get your patient out before the weekend, which is when nursing homes don't accept patients.
 
Oh, and also, use med students whenever you can. You can have them check labs, get official X-ray reports, fax stuff, etc... But make sure you make an attempt to teach them things in return.
 
good thread. efficiency is a grossly underrecognized skill that requires practice practice practice to get good at. I will add a few of my own pearls later, but others have mentioned most of the good ones. Dictating right away saves a buttload of time. Do it.
 
igotmyswag said:
I was just wondering if anyone could offer any suggestions to becoming an organized/efficient intern? I have a problem with being a bit unorganized in general and I was wondering if anyone had a particular method/procedure that they follow that tends to serve as a good template? I am open to any ideas that I can mend into my own plan; but I am trying to have my $h!t together for internship. The last thing I want to be is the unprepared intern or worse the one who stays until 10pm every night!
Click to expand...

Try and limit the number of things you have to carry around. Between books and notes, and PDAs and everything else, the volume of stuff you have to keep track of can become a bit crazy.

I've been using a PDA, but I'm a bit ambivalent about it. They're good to run something like epocrates on, and manage appointments, but they are underpowered and have a small screen. So if you're really looking to have a peripheral brain with you, they are of limited use I think.

I'm actually considering carrying around a small netbook or a tablet if I can find one. That would be the ultimate resource; I could put half a dozen textbooks on it, have portable access to google, manage my patients on a sticky type note system, and even type progress notes into word and print them out to include in charts. I type a lot faster than I write, and editing something digitally is much easier than realizing you forgot a couple of words 1/3rd down your note when you're done.
 
Two thoughts:

1) What you can do:
If you think about your typical day (pre-rounding, notes, orders, admissions, discharges), try group things together to minimize back-tracking. Examples - write all of your daily orders at once, make all of your follow-up appointments for all of your patients at once with a single phone call, send discharge meds to pharmacy at once.

Communicate with the nursing staff. Write orders (not just prn orders) with action requests. Example - "Page me when family arrives" "Page me if HR < 60, but not if patient is walking/talking, etc."

Start time-consuming tasks early. Discharge meds may take 2+ hours to fill, so send them early. You go home when your patient goes home, so get them out of there.

Try very hard to start discharge summaries early. Trying to re-create a hospital course is very painful and very time-consuming even 5 days later. The risk of missing something important is also higher.

2) What your team can do:
On all of the teams that I've been on, the interns agree to do the following on rounds: When the responsible intern is presenting, the other intern(s) write changes to orders, call consults, and send imaging/lab requests. This way, when you finish rounds, all the notes are done, all the orders are written, and you can spend the rest of the day admitting and discharging with minimal distractions.
 
Iwy Em Hotep said:
Two thoughts:

1) What you can do:
If you think about your typical day (pre-rounding, notes, orders, admissions, discharges), try group things together to minimize back-tracking. Examples - write all of your daily orders at once, make all of your follow-up appointments for all of your patients at once with a single phone call, send discharge meds to pharmacy at once.

Communicate with the nursing staff. Write orders (not just prn orders) with action requests. Example - "Page me when family arrives" "Page me if HR < 60, but not if patient is walking/talking, etc."

Start time-consuming tasks early. Discharge meds may take 2+ hours to fill, so send them early. You go home when your patient goes home, so get them out of there.

Try very hard to start discharge summaries early. Trying to re-create a hospital course is very painful and very time-consuming even 5 days later. The risk of missing something important is also higher.

2) What your team can do:
On all of the teams that I've been on, the interns agree to do the following on rounds: When the responsible intern is presenting, the other intern(s) write changes to orders, call consults, and send imaging/lab requests. This way, when you finish rounds, all the notes are done, all the orders are written, and you can spend the rest of the day admitting and discharging with minimal distractions.
Click to expand...

Thanks for all the advice, but the last one is especially sweet.
 
Iwy Em Hotep said:
2) What your team can do:
On all of the teams that I've been on, the interns agree to do the following on rounds: When the responsible intern is presenting, the other intern(s) write changes to orders, call consults, and send imaging/lab requests. This way, when you finish rounds, all the notes are done, all the orders are written, and you can spend the rest of the day admitting and discharging with minimal distractions.
Click to expand...

Yeah, but be careful with this one. If you have weak teammates, then it's safer and quicker to go it alone. You have to protect your patients and your workflow.

Where I did my internship, it was they PGY-2 on the team that put in the orders as the intern presented the daily SOAP to the attending. Usually, this worked well, but a couple of the PGY-2s (AMGs, for the record) and the CPOE were so bad that I spent more time double and triple-checking than if I could have just put the orders in myself (I caught big screw ups more than once).
 
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Your white coat pocket is a huge part of being organized & efficient during internship & residency.

First, some general concepts:

  1. Avoid having too many references - either too many books or too many apps
  2. Stick with the references you choose & become ultra-familiar with them... skim them during downtime
  3. Stay away from shiny objects - just because someone has the latest greatest gadget with the latest medical apps, doesn't mean that you should too... some people end up bouncing from one reference to the next to the next & one gadget to the next to the next... dangerous & distracting
Next some specifics:

  1. You need a drug reference
  2. You need a general discipline reference (medicine, surgery, OB, etc depending on which residency you're doing)
  3. You may want an on-call reference or a procedure reference
  4. That's a total of 2-4, no more than 4, no less than 2
Last, a shameless plug:

I addressed this in an old blog post. Check it out here: Internship References - 3 Things I Kept In My White Coat Pocket

I hope this helps.
 
I think it is also good to tell poop and fart jokes. Nurses love this, and they will be your best friends and audience.
 
I think the main thing I picked up during my intern year and I have taught all of my interns is the following:
every patient has a trajectory in the hospital. Some will two for two days, some two weeks, etc. The better you can get at predicting this trajectory the more you will be anticipating rather than reacting. This is particularly important with the heaviest workload involved with a patients hospitalization which is usually the 12-24hours around when they are admitted and the discharge process.
Work on being aggressive with discharge like a dog on a bone. At the end of every day, think about who might leave tomorrow. Make sure EVERYTHING is ready before you leave the hospital that day. DC summary, medications, f/u, transport, SNF/Rehab as needed, notification of PMD, discussion with patient and family, nursing manager aware. etc. etc. Do not accept a failed discharge. Too many times to count, my interns have told me that the discharge failed and when I looked into it, it was more a failure of will or preparation than anything else.

carry as little as you can get away with
 
I made myself a template page divided into three parts that I could fill in for each patient with daily labs, medication changes, pertinent medical issues, and of course, a checklist at the end. (The checklist was crucial!) I kept all this information in a binder that I divided by patient.

Other interns seemed to think I was very organized, so I at least gave the illusion of being organized.
 
Old_Mil said:
...I'm actually considering carrying around a small netbook or a tablet if I can find one. That would be the ultimate resource; I could put half a dozen textbooks on it, have portable access to google, manage my patients on a sticky type note system, and even type progress notes into word and print them out to include in charts. I type a lot faster than I write, and editing something digitally is much easier than realizing you forgot a couple of words 1/3rd down your note when you're done.
Click to expand...

Have you tried a netbook or a tablet yet?
 
I am already fairly organized and efficient- are there any advanced pearls/tricks/secrets out there? One basic one- I skeletonize my notes the day before, and incorporate them into my signout and vice versa. I always end up getting sleep on call, though my co-interns or residents may not... it's because sometimes they are just dilly-dallying or proceeding really slowly. Any tips on how to deal with a resident who is more slow than you are, and who doesn't put "getting out of the hospital on time" as a priority at all??

The biggest things that have delayed me have been external... like patient getting a picc before going to dialysis before going to IR before going to XYZ... suggestions on how to wade through these hospital-imposed delays??
 
I'm gonna bump this thread....

So - what I run into is this and I don't know how to deal with it ---

I get in early - around 05:30, rounds are at 09:00, I've got 5 patients...

Go through and see the patients, check with nurses before going in for overnight events. Usually takes about 45 minutes to get done.

So now is where we get bogged down...

For each patient:
1) review vitals and write them down for rounds.
2) review medications to see who got what when and if any changed overnight.
3) review insulin/D5 usage/glucose control.
4) review labs for new CBC/BMP/Ca/Mg/Phos values
5)Write all the above stuff down (except meds - note changes)
6)Review echos/EKGs/US/CXRs.
7)Review notes since I left the last one.
8) Write the note for each patient.
9) order daily labs, meds changes, etc.

I'm usually just squeaking in to be done and ready for rounds at 09:00....

I never had this much problem or took this much time as an MS3. I usually took 20 minutes per patient....What the hell am I doing wrong?
 
JustPlainBill said:
I'm gonna bump this thread....

So - what I run into is this and I don't know how to deal with it ---

I get in early - around 05:30, rounds are at 09:00, I've got 5 patients...
Click to expand...

I don't really know why that is taking you so long. That is nearly an hour per patient of prep work each morning.

Go through and see the patients, check with nurses before going in for overnight events. Usually takes about 45 minutes to get done.
Click to expand...

Checking on o/n events and briefly examining/interviewing patients on pre-rounds doesn't seem like it should take 45 minutes...

For each patient:
Click to expand...

I'm not trying to be judgmental...just trying to think through each of these tasks and figure out how much time it should take to do them

1) review vitals and write them down for rounds.
Click to expand...

Reviewing vitals seems like it should take 1-2 minutes max per patient. Maybe more if you come across an abnormality and want to look up how that was dealt with (i.e. - uop low, did they get some extra fluid)

2) review medications to see who got what when and if any changed
overnight.
Click to expand...

Are you getting any sign-out? Seems like you should already know from your 45 minutes of getting overnight events whether med changes were made. Now it is always good to look through the med list to verify that things are correct so I can't fault your thoroughness.

3) review insulin/D5 usage/glucose control.
Click to expand...

Again, unless are your patients are getting hypoglycemic and getting hit with D50 on a nightly basis, this should take less than 1min per patient

4) review labs for new CBC/BMP/Ca/Mg/Phos values
Click to expand...

Writing out the fishbone again...takes less than a minute

5)Write all the above stuff down (except meds - note changes)
Click to expand...

Should be writing as you go to increase efficiency. Writing the labs down actually helps me to review them as I am used to thinking about them in the order I write them.

6)Review echos/EKGs/US/CXRs.
Click to expand...

How many of your 5 patients are getting new echos overnight? I can't imagine there are more than 1 new study per patient to review.

7)Review notes since I left the last one.
8) Write the note for each patient.
Click to expand...

Note writing certainly takes time, and if it is expected that you will have notes completed before rounds that will eat up a chunk of time. If it is not expected, I would recommend thinking about doing this later in the day.

9) order daily labs, meds changes, etc.
Click to expand...

Some anticipation could help improve efficiency. Order routine AM labs the day before rather than early in the morning when you get in, etc.

I never had this much problem or took this much time as an MS3. I usually took 20 minutes per patient....What the hell am I doing wrong?
Click to expand...

Well you have some actual responsibility now...that is the big difference.

I don't know that you are doing anything "wrong" - you just need to find ways to increase your efficiency and eliminate any redundancy in your morning routine.

Also one thing I wonder about...what is the structure of your program's overnight care? Is it night float? A cross-covering on-call resident? Who is giving you sign-out in the morning? Good sign-out would help eliminate a lot of the steps you are taking each morning.
 
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Iwy Em Hotep said:
Two thoughts:

1) What you can do:
If you think about your typical day (pre-rounding, notes, orders, admissions, discharges), try group things together to minimize back-tracking. Examples - write all of your daily orders at once, make all of your follow-up appointments for all of your patients at once with a single phone call, send discharge meds to pharmacy at once.

Communicate with the nursing staff. Write orders (not just prn orders) with action requests. Example - "Page me when family arrives" "Page me if HR < 60, but not if patient is walking/talking, etc."

Start time-consuming tasks early. Discharge meds may take 2+ hours to fill, so send them early. You go home when your patient goes home, so get them out of there.

Try very hard to start discharge summaries early. Trying to re-create a hospital course is very painful and very time-consuming even 5 days later. The risk of missing something important is also higher.
Click to expand...

This is all really good advice. "Compartmentalizing" my day really helps. I make a little running list during rounds of which patients need consults called, who needs to get teed up for discharge, who needs a study, etc.

I prioritize time-critical tasks first (like if a pt needs an MRI to happen that day), then call critical consults, then finalize any discharges, then take care of the routine tasks after those big items are done.
 
southerIM --

I forgot to mention one little detail ---

Night float checks out to the 3rd year, not us interns. We also have a 2nd year who has determined that we are semi-complete Fups (not unreasonable at this stage of the game) and puts in orders and makes changes....sometimes they even remember to tell us...other times, they do it half-way or wait until attending rounds to tell us in front of the attending what was done overnight...and leave us looking like idiots who don't know what's going on with our patient....

I did manage to hit back one day...a procedure was postponed and the 2nd year didn't realize it and started trying to show off by pimping me in front of the attending about the procedure done 'last night'....I waited until they had a full head of steam and calmly told them it was postponed 2/2 patient positioning.....

but this same one also told me to order a wrong dose of anti-nausea med, then wouldn't own up to it when the 3rd year asked about it, made it look like my fault by saying they had already 'checked it out'.....

It's becoming a real pain and I don't know what to do....the 3rd year basically doesn't give a rats rip---just get the job done and don't violate duty hours, so we're stuck.....

and I get to deal with this for 2 years, 10 months and 1 week more...but who's counting...
 
JustPlainBill said:
southerIM --

I forgot to mention one little detail ---

Night float checks out to the 3rd year, not us interns. We also have a 2nd year who has determined that we are semi-complete Fups (not unreasonable at this stage of the game) and puts in orders and makes changes....sometimes they even remember to tell us...other times, they do it half-way or wait until attending rounds to tell us in front of the attending what was done overnight...and leave us looking like idiots who don't know what's going on with our patient....

I did manage to hit back one day...a procedure was postponed and the 2nd year didn't realize it and started trying to show off by pimping me in front of the attending about the procedure done 'last night'....I waited until they had a full head of steam and calmly told them it was postponed 2/2 patient positioning.....

but this same one also told me to order a wrong dose of anti-nausea med, then wouldn't own up to it when the 3rd year asked about it, made it look like my fault by saying they had already 'checked it out'.....

It's becoming a real pain and I don't know what to do....the 3rd year basically doesn't give a rats rip---just get the job done and don't violate duty hours, so we're stuck.....

and I get to deal with this for 2 years, 10 months and 1 week more...but who's counting...
Click to expand...

This sounds like a much bigger issue than just efficiency in pre-rounding
 
southernIM said:
This sounds like a much bigger issue than just efficiency in pre-rounding
Click to expand...

Tell me about it -

Another 2nd year taught me to noviry et proviry as Reagan told Gorby...
trust but verify....She freakin' told me a dosage on a med for a cardiac patient and I trusted her and reported it on rounds...it was wrong and not what was in the actual med list and the attending became annoyed and said to clear up the confusion...NOW. I turned to look at where I had gotten my data from and saw the scribbled note from the previous night's call in.....I confronted her gently and she got this goofy, 'oh crap, I've been caught' look, smiled a dorky smile and said,"Oh, I'm so sorry"....well that's fine, but own up to your mistake so the intern doesn't look like a dork, will ya.....

I'm not impressed with the 'own up to your screw ups' that is NOT being displayed by my 2nd years.....I find myself becoming less and less enamored with this program day by day.....

So to take it back to the thread...how do I cover my butt in this type of environment and get quick?
 
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igotmyswag said:
I was just wondering if anyone could offer any suggestions to becoming an organized/efficient intern? I have a problem with being a bit unorganized in general and I was wondering if anyone had a particular method/procedure that they follow that tends to serve as a good template? I am open to any ideas that I can mend into my own plan; but I am trying to have my $h!t together for internship. The last thing I want to be is the unprepared intern or worse the one who stays until 10pm every night!
Click to expand...
medicine is highly disorganized and inefficient so dont get your hopes up. the system is a big mess

if youre disorganized to begin with it will be tough. but youll get it.
 
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