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Categorical IM Intern, struggling of floors, needs advice
- Thread starter Weinberg Angle
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I can sympathize with you because I'm also a very detail oriented person... to the point where I completely miss certain differentials. For me, what helps me is taking a step back after I get the complete H&P of a patient. In the hecticness of things, I just have to just sit there for a few minutes and figure it all out. Those couple of minutes can make a tremendous difference. As for the memory thing, you've made it far enough into residency. So your memory is good enough! I know some people that started medical school at age 50, and they can still keep up with the younglings like myself! What they do is no different that what I do. I write everything thing. I go to medfools.com and print out those templates to help organize the patient data. It goes a long way. And you don't need to pull these things straight out of your memory. If someone mentions a patient to you with this and that, you should have a rough idea of which patient that somebody is talking about.
To make a long story short, I think you would benefit if you just take a few minutes out of your hectic day to breathe. The Picc line, IVF, etc questions can all be remembered if you take the few minutes after each patient to summarize them. Don't worry, you'll be fine.
To make a long story short, I think you would benefit if you just take a few minutes out of your hectic day to breathe. The Picc line, IVF, etc questions can all be remembered if you take the few minutes after each patient to summarize them. Don't worry, you'll be fine.
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I'm not an intern.
+ 1 about those scut sheets from medfools (http://www.medfools.com/wards.php)
I think getting nervous can really block your thinking. Many people have this issue. You need to learn how to chill out, and then I bet your memory will improve.
I do not know how things are done at your hospital. Generally on the floor, people prefer a problem-list assessment and plan. If you want to go ICU-style with:
Cardiovascular
Pulm
FEN
GI
Access
Etc.
This way you think systematically about your patient.
Then this may be a useful way to organize by system. Even on the regular floor, I think it is important to know I/O (especially since most patients have RI). The attending probably wanted to know about the PICC line because that means they can discharge the patient despite not having oral antibiotic therapy (or whatever else is lined up).
That is an important point to know... patient is here... how are we going to get them out of the hospital (how are we going to discharge) (do they need a PICC, transition abx to PO, bus ticket home, etc).
Your attending was probably wondering about the PICC for outpatient therapy. He may care about the I/Os... but what else is in the back of his mind is that the patient is attached to an IV pole and that needs to be disconnected before the patient is discharged (aka taking adequate PO). Basically, think of the primary problem, how you are going to treat it in the hospital, and how to detach the patient from everything (PICC, D/C IVFs, change to PO regimen) to get them out of the hospital.
It can be embarrassing to be an intern at times. We have these QA nurses that pop out of walls (it's seriously like those agents in the Matrix) and they know EVERYTHING about the patient. I've seen that happen to interns and even residents where the QA nurse pops out of a wall and mentions something even our attending was not quite aware of. These QA nurses are kind of like leprechauns, but so far, no luck following them to a pot of gold (heck, I don't even know where they are in the hospital... nobody really does).
In time, you'll learn efficiency (from what I hear from the current interns) and the more pertinent stuff.
Best wishes... I am sure you will improve in time.
+ 1 about those scut sheets from medfools (http://www.medfools.com/wards.php)
I think getting nervous can really block your thinking. Many people have this issue. You need to learn how to chill out, and then I bet your memory will improve.
I do not know how things are done at your hospital. Generally on the floor, people prefer a problem-list assessment and plan. If you want to go ICU-style with:
Cardiovascular
Pulm
FEN
GI
Access
Etc.
This way you think systematically about your patient.
Then this may be a useful way to organize by system. Even on the regular floor, I think it is important to know I/O (especially since most patients have RI). The attending probably wanted to know about the PICC line because that means they can discharge the patient despite not having oral antibiotic therapy (or whatever else is lined up).
That is an important point to know... patient is here... how are we going to get them out of the hospital (how are we going to discharge) (do they need a PICC, transition abx to PO, bus ticket home, etc).
Your attending was probably wondering about the PICC for outpatient therapy. He may care about the I/Os... but what else is in the back of his mind is that the patient is attached to an IV pole and that needs to be disconnected before the patient is discharged (aka taking adequate PO). Basically, think of the primary problem, how you are going to treat it in the hospital, and how to detach the patient from everything (PICC, D/C IVFs, change to PO regimen) to get them out of the hospital.
It can be embarrassing to be an intern at times. We have these QA nurses that pop out of walls (it's seriously like those agents in the Matrix) and they know EVERYTHING about the patient. I've seen that happen to interns and even residents where the QA nurse pops out of a wall and mentions something even our attending was not quite aware of. These QA nurses are kind of like leprechauns, but so far, no luck following them to a pot of gold (heck, I don't even know where they are in the hospital... nobody really does).
In time, you'll learn efficiency (from what I hear from the current interns) and the more pertinent stuff.
Best wishes... I am sure you will improve in time.
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I'm also not a resident yet, but FT is onto an important point: Learn why attendings ask the questions they do about patients.
Knowing that will probably prioritize that info in your memory banks
Knowing that will probably prioritize that info in your memory banks
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1. Issue #1 isn't as big an issue as you may think. I approach this from the other angle where I've got the big picture in mind but always gloss over the small details (something that has come up repeatedly during my evaluations). Personally, I think being mindful of details is more important and as others have posted, just take a short second after each H&P or progress note to sit back and put the details together in one coherent picture.
2. I have a similar issue with poor memory and agree that writing down everything is the way to go. No one has ever complained about my having to look at a note to remember things (especially as starting internship, we all have to deal with transforming from a medical student who carried at most 4-5 patients to now carrying 10-14 patients). My advice would be to be consistent in where you're placing this information on your notes so you can always scan QUICKLY and be able to provide the info promptly. For me, I always include IVF as part of a patient's daily meds. I always include lines (central and/or peripheral) and foleys near the input/output section of my vital signs AND the date on which they were placed. Again, if you are coming up with the answers PROMPTLY, I don't see why looking at your note would be frowned upon.
3. I can't answer this question as I'm not going to be a hospitalist. That being said, I'll admit to being shocked at (as well as carrying a great deal of respect for) the hospitalists who come to round on their 8-10 patients, without a sheet of paper, seemingly having EVERYTHING memorized including lab values from 72 hours ago. I have no idea how they do this. Perhaps it just comes with experience?
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1. I believe that "not seeing the forest for the trees" is really not an accurate assessment of the problem. A good internist knows all the details but effectively synthesizes the information into a coherent picture. They don't skip the details to get the big picture, they know the details and decide which details matter. My approach to this has always been the problem list. Identify and manage each problem. Once a given problem is done, get it out of your note and out of your presentation but keep it in mind. Work the problem list with a plan specific to each problem and you'll get the job done.
2. The nervousness probably comes, in part, from the fact that you feel like you are struggling. So, as your management skills improve, your presentations may also improve. Presenting is the key to getting good evals. Practice! This means taking time before rounds to briefly rehearse. They don't mind if you glance down at your paper for a detail but I bet you are staring at it or fumbling around. Write your cards the same way everytime, so you know where to quickly look. Again, a good problem list with a plan will help here.
3. Hospitalists call lots of consults. They need to be able to summarize patient hx and hospital course in a few sentences. The people they are calling all really appreciate that.
Good luck.
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Above all - don't give up. All of those wonderful physicians started off as bumbling interns and got better just as you are, with hard work and knowledge of their deficiencies. It seems like you've done a great job identifying what you need to get you where you want to be. Also, a little positive mental imaging couldn't hurt either - instead of worrying ahead to the future and picturing yourself failing, why not take a minute or two to picture yourself confident and in charge, able to give the salient points quickly and rattle off the details without a problem. Couldn't hurt!
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Just out of curiosity, what have your senior residents been doing to help you? Your failure is their failure. They should know the way the attendings want things presented and should guide you. They were also interns recently (some just last year) and probably struggled with some of these same issues. Ask them for help, that's what they're there for.
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I really appreciate this thread... I have had "floors issues" of my own...
I'll piggyback on this and ask the collected wisdom:
Sometimes I get so caught up in trying to move from admission to admission on a busy call that I don't stop and think to do simple things as part of my admission orders. What kind of "standard" admission orders do you write when you admit your patients? Obviously, obviously, this is situation dependent, but what are some things that you think about with every admission to make your life (and the cross-cover's life) easier? Eg,
Tylenol prn pain/fever
mylanta prn indigestion (tums for ESRDers)
SSI
NHO parameters
Other things I wonder about but don't do:
Does anyone do anything like prn hydralazine or clonidine for HTN as part of every admission?
Is it ever OK to write standing orders to pan-culture/CXR patients that spike fevers so they don't bother the cross-cover with a 101?
What about "SL nitro/CXR/CE's/EKG & page HO when results complete" for chest pain?
Some of these are clearly situations in which an MD needs to evaluate the patient, but it would make your friendly cross-cover's life easier if they got a page that said "hello Doc, this patient has chest pain; EKG/CE's and CXR are ready for you". You could argue that some clinical judgment should be exercised in working up every CP, but you could also argue that anytime the staff is concerned enough to notify you about CP you are obligated to make at least a minimal investigation into it.
I'll piggyback on this and ask the collected wisdom:
Sometimes I get so caught up in trying to move from admission to admission on a busy call that I don't stop and think to do simple things as part of my admission orders. What kind of "standard" admission orders do you write when you admit your patients? Obviously, obviously, this is situation dependent, but what are some things that you think about with every admission to make your life (and the cross-cover's life) easier? Eg,
Tylenol prn pain/fever
mylanta prn indigestion (tums for ESRDers)
SSI
NHO parameters
Other things I wonder about but don't do:
Does anyone do anything like prn hydralazine or clonidine for HTN as part of every admission?
Is it ever OK to write standing orders to pan-culture/CXR patients that spike fevers so they don't bother the cross-cover with a 101?
What about "SL nitro/CXR/CE's/EKG & page HO when results complete" for chest pain?
Some of these are clearly situations in which an MD needs to evaluate the patient, but it would make your friendly cross-cover's life easier if they got a page that said "hello Doc, this patient has chest pain; EKG/CE's and CXR are ready for you". You could argue that some clinical judgment should be exercised in working up every CP, but you could also argue that anytime the staff is concerned enough to notify you about CP you are obligated to make at least a minimal investigation into it.
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As you mentioned...it's all situation specific. But some common standard orders I use are:
ISS
hep SQ
tylenol PRN
zofran
I would not recommend standing PRN BP meds unless the pt came in w/ difficult to control Htn. It's better to be called about htn and adjust the standing meds as needed in a thoughtful manner. Otherwise you might glance at the vitals and think the BP is under control when in fact they're getting PRN hydralazine around the clock.
I would also avoid standing orders for blood cx's/UA/CXR for fevers or EKG/trop/CXR for chest pain because it can lead to the x-cover missing something (or not even being called) because it's all automated. Which also means you might not know anything was amiss overnight when you return in the AM. Make 'em THINK when the RN's call...that's how x-cover interns learn. Also, some pts have recurrent atypical CP nightly and standing orders as mentioned above would get pretty expensive and tedious for simple GERD. Same is true for a pt who's persistently febrile and already had the infectious w/u done in the last 24hrs.
If you really want to help your x-cover out, mention in sign-out what you would do if "x" happens (eg- you're afraid Ms. Smith, who has diarrhea & leukocytosis but was cdiff neg x 1, might spike a fever or clinically decline overnight...so you leave in the To Do List: "Please repeat blood cx's x2 and consider starting flagyl 500mg TID if she spikes tonight.") Sometimes providing a general game plan for your x-cover can be the most helpful thing you do.
ISS
hep SQ
tylenol PRN
zofran
I would not recommend standing PRN BP meds unless the pt came in w/ difficult to control Htn. It's better to be called about htn and adjust the standing meds as needed in a thoughtful manner. Otherwise you might glance at the vitals and think the BP is under control when in fact they're getting PRN hydralazine around the clock.
I would also avoid standing orders for blood cx's/UA/CXR for fevers or EKG/trop/CXR for chest pain because it can lead to the x-cover missing something (or not even being called) because it's all automated. Which also means you might not know anything was amiss overnight when you return in the AM. Make 'em THINK when the RN's call...that's how x-cover interns learn. Also, some pts have recurrent atypical CP nightly and standing orders as mentioned above would get pretty expensive and tedious for simple GERD. Same is true for a pt who's persistently febrile and already had the infectious w/u done in the last 24hrs.
If you really want to help your x-cover out, mention in sign-out what you would do if "x" happens (eg- you're afraid Ms. Smith, who has diarrhea & leukocytosis but was cdiff neg x 1, might spike a fever or clinically decline overnight...so you leave in the To Do List: "Please repeat blood cx's x2 and consider starting flagyl 500mg TID if she spikes tonight.") Sometimes providing a general game plan for your x-cover can be the most helpful thing you do.
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not really sure what else to add.
at a minimum, you just need to remember: who are they, why are they here, what are we doing for them. the rest is details.
with that being said, don't be afraid to ask for help- from other interns, junior/senior residents, and attendings. when i was a resident, i loved interns who asked what they could do to do better/improve.
to add, different consultants will want to know different things. but in the end, you pretty much want to ask a question.
gi - "hi, i've got this lady who's 65, never had a colo, came in with meleneic stools... she's responded well to transfusion, but i think she oughta get a colo. what do you think?"
surg - "hi, i've got this lady who's 65, came in with meleneic stools... got scoped, and we found a mass. wanted to see if you think she can get an ex-lap."
heme/onc - "hi, i've got this lady who came in with a lower gi bleed. did a colo and ex-lap, looks like she has colo cancer. wanted to see if you could give some recs."
of course it doesn't always happen that way in real time. but you don't always have to give a bunch of details over the phone.
again, who are they, why are they here, what are we doing for them?
for your consultants, the last question becomes what do you want the consultant to do for your patient?
at a minimum, you just need to remember: who are they, why are they here, what are we doing for them. the rest is details.
with that being said, don't be afraid to ask for help- from other interns, junior/senior residents, and attendings. when i was a resident, i loved interns who asked what they could do to do better/improve.
to add, different consultants will want to know different things. but in the end, you pretty much want to ask a question.
gi - "hi, i've got this lady who's 65, never had a colo, came in with meleneic stools... she's responded well to transfusion, but i think she oughta get a colo. what do you think?"
surg - "hi, i've got this lady who's 65, came in with meleneic stools... got scoped, and we found a mass. wanted to see if you think she can get an ex-lap."
heme/onc - "hi, i've got this lady who came in with a lower gi bleed. did a colo and ex-lap, looks like she has colo cancer. wanted to see if you could give some recs."
of course it doesn't always happen that way in real time. but you don't always have to give a bunch of details over the phone.
again, who are they, why are they here, what are we doing for them?
for your consultants, the last question becomes what do you want the consultant to do for your patient?
This may sound corny, but I have found that when I approach a patient as an individual with a unique story, I naturally remember more about them. It was much more natural to recount their stories when I had been engaged with them during the H&P and only took bare-minimum notes that would help jog my memory later.
It's kinda like going on vacation...you can take a million pictures and remember the place through a camera lens - or you can just take in the sights and have the full experience.
During residency, I had more trouble with patients I picked up from the night float team - so I made the effort (when I could - being realistic) to take a few extra minutes to get acquainted with them as people and get a sense of what made them standout. That way, I didn't think, "does Patient #10 have a foley?" - rather I would think "Did Mr. Jones who is a WWII vet have a bag hangin' off the bed when we were talking?"
This is just one of many techniques that may/may not help you - but it might be worth a try...
It's kinda like going on vacation...you can take a million pictures and remember the place through a camera lens - or you can just take in the sights and have the full experience.
During residency, I had more trouble with patients I picked up from the night float team - so I made the effort (when I could - being realistic) to take a few extra minutes to get acquainted with them as people and get a sense of what made them standout. That way, I didn't think, "does Patient #10 have a foley?" - rather I would think "Did Mr. Jones who is a WWII vet have a bag hangin' off the bed when we were talking?"
This is just one of many techniques that may/may not help you - but it might be worth a try...
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This is not corny at all, as I was reading through this post and the excellent suggestions made thus far, I was actually wondering if someone uses this method that generally works for me. Photographic memory and an occasional joke you share with a patient during H/P takes you back to that situation (flashes like a scene in my head and then I just have to remember seeing a foley or a picc when I was talking to them). I have the most trouble remember patient details (out of memory) if I only meagerly connected with the patient.
2. I have a similar issue with poor memory and agree that writing down everything is the way to go. No one has ever complained about my having to look at a note to remember things (especially as starting internship, we all have to deal with transforming from a medical student who carried at most 4-5 patients to now carrying 10-14 patients). My advice would be to be consistent in where you're placing this information on your notes so you can always scan QUICKLY and be able to provide the info promptly. For me, I always include IVF as part of a patient's daily meds. I always include lines (central and/or peripheral) and foleys near the input/output section of my vital signs AND the date on which they were placed. Again, if you are coming up with the answers PROMPTLY, I don't see why looking at your note would be frowned upon.
/QUOTE]
asmallchild's suggestion is way more responsible though, rather than relying on your photographic memory that not too often ditches you at nick time.
All in all, so many good options to choose from.
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I did a medicine internship, anesthesiology residency, and pain medicine fellowship. I suffered through what you're talking about on and off with various attendings. I'm in private practice now, and get to call the shots as I see 'em, and it's a whole new (better) world.
The fundamental problem with looking good before attendings as an intern (and resident) is that they get to decide what facts are important, and you are expected to read their minds. As an intern, you have no clue what's important yet- learning that is a big part of what internship is about.
The further along you get, the better you will be able to recognize the important details. You will remember them because they'll be important to you making the patient better, or kicking them out the door. Don't waste too much time writing stuff down. See if your hospital's computer system has a way to automatically print out composites of labs, nursing records, imaging, notes etc, so you have a daily reference for details. You'll kill a few trees with all the paper you waste, but it's worth it. Just remember to recycle.
You will ALWAYS have attendings who are occasionally (or frequently) WRONG OR NUTS. You will NEVER be able to read their minds. Just roll with the punches, and don't get fired. Try not to feel bad if you can't do everything perfectly or even well according to someone else's standards- it's a very hard job that some are more talented at than others.
Ultimately if you are conscientious, honest, smart, creative, and caring, you will do fine.
The fundamental problem with looking good before attendings as an intern (and resident) is that they get to decide what facts are important, and you are expected to read their minds. As an intern, you have no clue what's important yet- learning that is a big part of what internship is about.
The further along you get, the better you will be able to recognize the important details. You will remember them because they'll be important to you making the patient better, or kicking them out the door. Don't waste too much time writing stuff down. See if your hospital's computer system has a way to automatically print out composites of labs, nursing records, imaging, notes etc, so you have a daily reference for details. You'll kill a few trees with all the paper you waste, but it's worth it. Just remember to recycle.
You will ALWAYS have attendings who are occasionally (or frequently) WRONG OR NUTS. You will NEVER be able to read their minds. Just roll with the punches, and don't get fired. Try not to feel bad if you can't do everything perfectly or even well according to someone else's standards- it's a very hard job that some are more talented at than others.
Ultimately if you are conscientious, honest, smart, creative, and caring, you will do fine.
