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Biggest Mistakes
- Thread starter BDylan
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Thank you, it is nice to have this common sense stuff reaffirmed and in one place.
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Surviving intern year:
1) Don't piss off the ancillary staff!!!! The nurses and staff can be your biggest allies...or your very worst enemies. Especially in the beginning of the year when you know close to zero. Always be polite, asking nicely. There's no need for brownnosing, but being patient, polite and humble goes a very long way.
2) Remember you may be a physician in name but you still don't know much more than you did as a 4th year medical student. Just be humble.
3) Don't be afraid to ask for help. It's always better to ask for help when in doubt. It's better to be safe than sorry.
4) The Golden Rule (modified): Don't sign out something that you wouldn't want someone to sign to you. That being said, trying to anticipate what people need to know about your patients, and put it on the signout. Patient will be discharged tomorrow, (is all the paperwork done, do they need scripts, Page 1?)
5) Read, read, read. Try to learn one new thing everyday. Uptodate is a good source.
6) Get Step 3 done as soon as possible. It's not that bad.
Have fun, learn, be safe.
Those are pretty good thoughts. I would defintely say read everyday, the residents who try to just "learn on the job" and put off studying stick out like sore thumbs and slows the team down when an attending has to explain something simple to them. I would aim for reading 2-3 hours a night. Also, the greatest recent gift to medical continuing education is the iPod, I only got one when I figured out how to download medical lectures, you can also earn CME credit this way. If you have a reasonable commute i.e. >20 minutes you can actually make the time productive, all of these little bits of studying add up. Vacations can be a good time to study, sit back and listen to internal medicine, pediatrics lectures when traveling, again every little bit helps. And please please please be nice to us students!
As far as reporting impaired physicians, I would do it as anonymously as possible. When a student or resident reports an attending it automatically becomes a power issue and attendings will and do close ranks. Of course if someone is impaired you must do something to help them and make sure they don't hurt patients, but, realistically even if you are right you will often be subject to some form of retaliation on an subconcious level. I have heard of a student being put in the very uncomfortable position of reporting a physician who was "impaired" for the good of all. The fellow attendings decided not to do anything. The ultimate responsibility lies firmly on the shoulders of fellow attendings at whatever institution the impaired physician works at who almost invariably know what is going on, don't be the "fall guy" and sacrifice yourself, do it anonymously, only another attending has the power to force another attending to become "unimpaired."
Just a small thing, but I wish, I would have known this.
One thing I got burned with- don't write orders thinking nurses will use their brain to interpret:
I wrote for ativan 0.5-1mg IV before a procedure. RN gave 1 mg IV push and patient nearly stopped breathing (was quadriplegic, emaciated).
I thought, she would understand it the way I would have given the drug- try 0.5, see how he does, then give more as needed.
What I should have written was:
Ativan 0.5 mg IV x1, may repeat x 1.
Have fun, it's only one year of pain...
One thing I got burned with- don't write orders thinking nurses will use their brain to interpret:
I wrote for ativan 0.5-1mg IV before a procedure. RN gave 1 mg IV push and patient nearly stopped breathing (was quadriplegic, emaciated).
I thought, she would understand it the way I would have given the drug- try 0.5, see how he does, then give more as needed.
What I should have written was:
Ativan 0.5 mg IV x1, may repeat x 1.
Have fun, it's only one year of pain...
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Sign-out is probably the place where interns (myself included) make the biggest, or at least most common, mistakes.
If you're going to sign out "follow up on X" be sure to include what to do about X. Such as, "f/u K @ 2000, was 2.8 this AM, getting IV and PO replacement, if <3.5, check infusion and adjust PRN."
Following up imaging studies is a pet peeve. If you're getting a STAT MRI to r/o cord compression, don't sign that out, stick around to follow that up. If, OTOH, you got a staging CT in a guy w/ newly dx'd colorectal Ca, don't sign that out (unless he's got AMS and you're looking for brain mets in which case your ED really screwed up by not getting that before he came upstairs).
Most importantly, and I mean it...thy sign out shall be no more than 1 page. Period. Trauma surgery can sign out 45 patients on one page, your 6 medicine patients can fit in that space too. 6 pt fonts were made for a reason.
And finally, if you expect (or wouldn't be surprised if) someone on your service to die overnight, SIGN THAT OUT and be sure to include code status, whether or not the attending wants to hear about it and a family contact # so your cross-cover colleague doesn't have to go chart diving @ 0300 to find the contact info on a dying patient to see if he's really Full Code or not. I've seen more than 1 case of an attending and family members of a deceased pt riding in an elevator together @ 7am and the attending, who hadn't been paged about the patient's death, asking, "so, how's Mr. Jones today."
Be clear, be concise and be conscientious.
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I'm loving this article.
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I was away for a friend's wedding. Came back and had to go in on Sunday to check labs. One of my co-interns had left me a list of labs to check as we cross cover for each other at my program. One of the signouts was to check plt on a patient with pancytopenia on the onc floor. The signout was to transfuse if plt<5,000. So I checked the labs and the plts were like 9,000, so I went on to the next one. I come in the next day and my co-intern was like "did you transfuse plts on my patient? Her plts were 3,000 yesterday and her foley bag is all RED..." I quickly checked the labs again.. Apparently I had checked the labs from the WRONG DAY (had been away for 3 days and confused the dates when I got back)... The labs from the day I was supposed to have checked did not register into the computer until after I had checked them. Ugh..
Well, the patient got her platelet transfusion one day late. It was my first month, so there really weren't any repercussions other than being told to be careful next time.
I think I like the thread about the nurse's mistakes better...
Well, the patient got her platelet transfusion one day late. It was my first month, so there really weren't any repercussions other than being told to be careful next time.
I think I like the thread about the nurse's mistakes better...
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Do a google search for audio lectures and 1. your area of specialty, 2. Step 1 Prep, 3. Step 2 Prep, 4. Step 3 Prep, etc . . . You can also fit alot of hours of video lectures onto the big iPod, and just listen to the audio as you drive. If you have a subscript to NEJM they do these podcasts that you can listen to as well, alot of medical schools and residencies have free podcasts that you can subscribe to as well. Google CME audio lecuters, you could probably use educational funds to get 'em as alot cost as much as a big textbook but have a TON of lectures. . .
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I disagree. Don`t read on your days off, if you are human and therefore need a break from time to time. If you get yourself refreshed every now and then, you will be able to work harder when you are at work and take in information better when you are learning. In other words: work hard 👍, and when you do have a day off, sleep hard. 😴
Obviously, if you worked very hard on a Friday, left at say 7:30 pm, crashed, then if you slept in until 10:30 am, ate a leisurely lunch at noon, no one would fault you. But, if over a golden weekend off, you didn't do *any* reading, or any reading ever on a day off it will catch up with you. Remember, it is hard to get quality reading time in after a work day, i.e. for a couple of hours at night, although you should try. The days off are perfect because you can sit down for several hours and actually read something and concentrate solely on that. You can't learn medicine solely "on the job", i.e. learning by doing, you have to read as well. Nothing is more annoying for us med students who study everyday, and hard studying residents and attendings, to have a resident who yaps about going out on the weekend and obviously is behind in their knowledge/management base.
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I'm with you on this. If you need to look up something specific related to a patient do so. Shouldn't take more than 10 minutes to do that. If it is more general background on a condition or treatment, then for interns or anyone doing q4 type 60-80 hour weeks, I'd rather have them relax in their spare time and wait for another time to do extensive reading. Clearly, if one has specific academic problems, more reading is needed, but that's not what was proposed. What was said was that all residents should read 60 minutes every day except vacations.
My experience is that interns and residents are much happier and more productive when they are, um, having quality interactive time with a significant other for 60 minutes each day than reading a textbook or medical journal. YMMV of course.
Then again, I'm not and never have been or will be a program director.....
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... that`s not me. Learning styles obviously differ, but I found I like medical knowledge so much that it sticks the first time around, if I take the luxury of actually creating "study-free zones" in the calendar. Even though they may be in the minority - you`re right on that.
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If you have itunes do a search for This Week in Med School. Then check the "listeners also subscribed to" links and just follow those. I subscribe to about 7 of them and listen to them while I surf the net.
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What you mean is: "Don't write orders thinking the nurses can read your mind."
This is a classic example of why a lot of hospitals have banned range orders. Maybe that was what you wanted, but that is not what your order stated. Your second example clearly says what you want.
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Here's a great link for good medical podcasts:
http://www.newmediamedicine.com/blog/2006/08/05/medical-podcasts/
Word
http://www.newmediamedicine.com/blog/2006/08/05/medical-podcasts/
Word
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Just curious, does it make you feel at all awkward to be a med student telling interns and residents the best way to maximize their training time?
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biggest mistake - taking an order from a nurse.
seriously, it's obvious yes, but when new on the job and with very aggresive nurses who think they know better than doctors, just call your senior when they say things like ' i know what needs to be done, i just need an order written', well... there's a reason why they need an order written - half the time they know only half the story and bottom line - they did NOT go to medical school.
seriously, it's obvious yes, but when new on the job and with very aggresive nurses who think they know better than doctors, just call your senior when they say things like ' i know what needs to be done, i just need an order written', well... there's a reason why they need an order written - half the time they know only half the story and bottom line - they did NOT go to medical school.
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As an ICU nurse, I find it a tad bit insulting what one poster said about that ativan order he or she wrote. Bottom line, the order was written to allow the nurse to administer 0.5 to 1.0 mg of ativan...you're the one who wrote the order incorrectly. Now if I had been the nurse, I definitely would have administered .5 first if the patient had not received ativan before. However, the nurse technically did nothing wrong under your order. The negligence would be on you, not him or her - if there had been a permanent bad outcome.
I never push my ideas on residents - I tend to have a good working knowledge of my particular specialty. I know I didn't go to med school (I could, but I do not want to) and I would never assumeb my clinical experience substitutes formal education. However, I am a smart person with common sense (something a few MDs and nurses do not have at all). I have access to and read "up to date" etc and I am constantly looking things up I do not know in order to learn more.
Anyway, I never underestimate any intern because I respect them and know that all are very smart and hard workers. I suggest all of you new interns not underestimate the nurses. If I can say one thing about my experience, my nurse's instinct is accurate about 99% of the time - if someone is crumping before they look they are, and I tell you...listen!! I promise I'll be right. It comes with seeing 50% + of your MSOF patients decline and die. Further, I care about being a nurturing person - and that includes helping the interns with the day to day functional aspects of their job that I guarantee the medical staff will not tell y'all enough about - but if an intern is smug and rude, I would be less inclined to help him or her figure out the tricks of the trade. Have a good one.
I never push my ideas on residents - I tend to have a good working knowledge of my particular specialty. I know I didn't go to med school (I could, but I do not want to) and I would never assumeb my clinical experience substitutes formal education. However, I am a smart person with common sense (something a few MDs and nurses do not have at all). I have access to and read "up to date" etc and I am constantly looking things up I do not know in order to learn more.
Anyway, I never underestimate any intern because I respect them and know that all are very smart and hard workers. I suggest all of you new interns not underestimate the nurses. If I can say one thing about my experience, my nurse's instinct is accurate about 99% of the time - if someone is crumping before they look they are, and I tell you...listen!! I promise I'll be right. It comes with seeing 50% + of your MSOF patients decline and die. Further, I care about being a nurturing person - and that includes helping the interns with the day to day functional aspects of their job that I guarantee the medical staff will not tell y'all enough about - but if an intern is smug and rude, I would be less inclined to help him or her figure out the tricks of the trade. Have a good one.
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I was just going to say it is annoying because it proves to those people who study that much that they really are dumb ****s, and can't pick up stuff even reasonably quickly.
S
saiyagirl
as a med student, i will say that there are, in fact, more annoying things. at the top of the list are other med students who talk like they know everything.
i've made the mistake before. so here's my advice to you. from one student to another. i would advise you to nix giving job advice to your superiors or else one day your actions will bite you in the ass. and even if you think you do know better, well then smile and keep it to your self, cause you don't want to be "that annoying" med student. trust me. be humble. at least admit in your posts that you are not a resident and never have been if you absolutely cannot refrain from offering your two cents. learn some social graces.
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She's pretty damn annoyiing, that's for sure. Hope you're not at my program.
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I gotta say, I'm a med student and I really DO NOT study that hard, I think residents and interns study much harder.... unless ofcourse you're talking about the preclinical years..... than I agree...
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At first I just thought ChildNeuro was just a dorky resident, but as more garbage spewed forth from her post she said she was a med student? Wow, you got it all figured out, don't you? As a resident I am sure as hell not gonna read on my days off. Please go get laid, get drunk or both. If you look anything like your avatar, maybe I could help you out.
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I was especially tickled by her "hard studying attendings" line. I think 90% of attendings actually have a life and don't go home and stick their nose in a book when they get off work.
Barring your lack of tact and social graces, I have to applaud your study ethic - hopefully you will find a specialty where human contact is minimal.
Barring your lack of tact and social graces, I have to applaud your study ethic - hopefully you will find a specialty where human contact is minimal.
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well said.
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I wrote for "100mg dilaudid x 1" once when I meant "100mg dilantin x 1" once when I was exhausted. Luckily I was telling the nurse what I want as I wrote it, and she gave the 100mg dilantin. I ended up having to talk to the ACR.
I also D/C someone because I thought they had AFB stain negative x 3, and the ID consult said "TB highly unlikely". Turns out, the lab does one run with the sputum, then repeats it with concentrated sputum. The normal concentration was negative, but all three concentrated sputums were positive. In this case I also exposed myself many times to active TB.
I also D/C someone because I thought they had AFB stain negative x 3, and the ID consult said "TB highly unlikely". Turns out, the lab does one run with the sputum, then repeats it with concentrated sputum. The normal concentration was negative, but all three concentrated sputums were positive. In this case I also exposed myself many times to active TB.
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On one of my earliest ward months, I wrote for a patient to receive 40meq KCl q4h. Of course, I intended to add a comment "x 2 doses for a total of 80meq", but I was post-call, utterly exhausted, and completely forgot. Luckily, I had a great upper level who meticulously checked all of our orders (in that awesome discrete way where you don't know he's doing it unless you screw something up). He caught it, changed the order, and didn't say anything about it until the next day when I was well-rested. Then he gently let me know that I almost killed a man 😱
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This advice is silly at best. I just dont think there are enough hours in the day. Though I knew one intern who probably approached reading this much and had a amazing fund of knowledge for an intern but was also socially inept and abrasive, he was not offered a contract renewal for second year.
Regardless you should read frequently, if only a section from UTD about something on Pt your following. I flip through a Washington manual and/or a JAMA while on throne and that ensures I read daily, but it is usually not 2-3 hrs of reading😀.
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Seriously?
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Dude, that was 8 years ago.
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Entered in error. Responding to post from 8 years ago.
Are you freaking serious?
While I appreciate your perspective as a member of the team, I can't imagine you work with any given resident more than like what, max 2 months in your 4 years as a med student? Yes, life is hard for the med student. What was hard about being a med student was being **** on when I wasn't being ignored, reading my ass off so that when I get pimped I knew something, and the long hours and sleep deprivation, and putting way too much effort into every little detail about like 2 patients so I could memorize what they ate for breakfast and repeat it perfectly like a robot and write notes the size of Shakespeare plays. As an intern, they're still just as inclined to **** on you, only now they're watching you constantly, increasing the amount of **** you get, and the hours are longer and the sleep deprivation is worse, and you have literally 3x as many notes to write and all the orders and admits and pages, and everybody wants a piece of you. No amount of reading prepared me for residency. I think the first half of intern year you're busy learning to apply what you already know, and desperately reading as fast as you can about what you don't so you can get **** done, but the first half of the year is easily just learning the system and how the parts work together and recognizing sick from not sick and the nuances of practicing. I always heard you should read every day, even if it's just for 10 minutes. Believe me, I did that and then some just being on the ****ing job. Sure, later on I think it's important to read more, but this idea of residents reading 2-3 hours a night so they can look good to the med students is just ridiculously out of touch with the reality of being a resident.
The attending cares a lot more about how well the service is being run, the plans put before him and the orders written, and that is a reflection of knowledge base. Doing the right thing. If you're doing that well and otherwise appear to go into an absence seizure when it's pimping time, nobody cares.
And I never talk about how great my weekend or vacation was. I keep it positive, tame, vague, and mostly brief, just so I don't have to deal with the judgement.
