Drowning first few days of internship

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rd31

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I'm a week into my intern year in the ICU of a major referral center. The patients are sicker than any I've ever seen. I look like a total ***** on rounds and everyone probably thinks I function at the level of an MSIII (thank you, MSIV year). I'm overwhelmed by the data collection process alone (with a super convoluted EMR) that I'm not able to formulate complete or thoughtful plans by the time rounds start. This is despite coming in an hour earlier than the rest of the day team (and breaking duty hours). I also failed at my first few procedures that my resident thought were easy. I'm so tired and defeated at the end of the day that I just don't have the energy to read much and I prioritize dinner (often my only meal of the day) and my sleep (~ 5-6 hours/night).

I'm sure my evaluations from this rotation will be abysmal. My question is, how much weight is given to the evals early in the intern year? Does the PD usually not care about evals until a certain part of the year? I see all these threads about residents being fired and I wake up every morning worried about this...
 
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I spent my first rotation (5 1/2 weeks) in the MICU as well. It was before they switched to night float so I was doing Q4 overnights. I'd never done an ICU rotation. The only reason I didn't cry every night when I went home was because I usually fell asleep first. You will get faster. You will get better. You will learn a s**t-ton. You'll be fine.
 
I started my residency with MICU as well. on top of that I am a carribean grad, (so I was probably even less prepared)
The first few months is all about not getting discouraged and moving forward. Take everything as constructive criticism and slowly things will start clicking. It takes about 3-4 floor months before you start feeling comfortable.
 
You're supposed to feel that way. If you were overworked and terrified, you're probably lazy and killing people.
 
it is a tough transition, but you will be fine once you know the system better. I bet by week 2-3 you will feel like an old pro.
 
had MICU after only 2 weeks of floor service...ran half stupid and half scared the whole month...but you learn...just do what you are told to do...have all the numbers (even if you don't understand what they mean) and be up to date with your patients' status...and if you get the chance, chat with the RTs...they can teach you a lot...

the bonus of MICU so early...NF float not as scary... 🙂
 
rokshana said:
had MICU after only 2 weeks of floor service...ran half stupid and half scared the whole month...but you learn...just do what you are told to do...have all the numbers (even if you don't understand what they mean) and be up to date with your patients' status...and if you get the chance, chat with the RTs...they can teach you a lot...

the bonus of MICU so early...NF float not as scary... 🙂
Click to expand...

Was still scary for me 🙂 NF at my program a whole other beast.
 
rd31 said:
I'm a week into my intern year in the ICU of a major referral center. The patients are sicker than any I've ever seen. I look like a total ***** on rounds and everyone probably thinks I function at the level of an MSIII (thank you, MSIV year). I'm overwhelmed by the data collection process alone (with a super convoluted EMR) that I'm not able to formulate complete or thoughtful plans by the time rounds start. This is despite coming in an hour earlier than the rest of the day team (and breaking duty hours). I also failed at my first few procedures that my resident thought were easy. I'm so tired and defeated at the end of the day that I just don't have the energy to read much and I prioritize dinner (often my only meal of the day) and my sleep (~ 5-6 hours/night).

I'm sure my evaluations from this rotation will be abysmal. My question is, how much weight is given to the evals early in the intern year? Does the PD usually not care about evals until a certain part of the year? I see all these threads about residents being fired and I wake up every morning worried about this...
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An intern in July in the MICU who is confident is a dangerous intern. You're doing fine - the seniors are watching you like a hawk, and so are the nurses, RTs, attendings, etc. Expectations of a beginning intern in the MICU is different than a late intern (about to become a junior resident) in the MICU. Hopefully the seniors will also remember what it was like to be in the MICU as an intern (and what it was like to start off on a service with new EMR, new hospital, new staff, etc)

Don't worry about reading too much. Nothing wrong with prioritizing sleep and dinner over reading. At this point you're trying to learn how to gather the information. Later in your training, you'll learn what numbers to focus on and what they mean. Only after that can you truly formulate a plan.
 
Your problems are really small

1. Breaking duty hours? I think you need to think about this comment before discussing it further.
2. Procedures? generally irrelevant in the eyes of the PD unless you actually want to do an ICU fellowship
3. On Rounds: Only your assessment and plans show how smart you are anyways, so formulate it the day before. Dont waste time presenting useless history and physical or labs. If you want to sound smart, present your plan first, and when the attending questions why, then you bring up pertinent history physical and labs.
 
Hi rd31 - you are not alone, and you are not going to get fired. Remember that residency is the hardest part of training, intern year is the hardest part of residency, the first week is probably the hardest part of intern year, and university MICU is probably the hardest possible way to start off intern year.

You are at a top 5/10 IM program, are you not? As someone at a similar program, let me pass along some pearls from a "what I knew when I started internship" document that we were given during orientation and that has been handy during these crazy first few days:

- Cut yourself some slack - you are going to be your own harshest critic during intern year. It goes a lot more smoothly if you know this in advance.
- The longer you stay, the longer you stay.
- Patients like you.
- You are absolutely ready for this.
- You absolutely belong here.
- Each day gets easier.
- Your fellow interns all feel the same way, so make sure to talk to them.
- You are not alone!
- Intern year is an amazing time of learning and growth and you will remember it for the rest of your life!
 
group_theory said:
An intern in July in the MICU who is confident is a dangerous intern. You're doing fine - the seniors are watching you like a hawk, and so are the nurses, RTs, attendings, etc. Expectations of a beginning intern in the MICU is different than a late intern (about to become a junior resident) in the MICU. Hopefully the seniors will also remember what it was like to be in the MICU as an intern (and what it was like to start off on a service with new EMR, new hospital, new staff, etc)

Don't worry about reading too much. Nothing wrong with prioritizing sleep and dinner over reading. At this point you're trying to learn how to gather the information. Later in your training, you'll learn what numbers to focus on and what they mean. Only after that can you truly formulate a plan.
Click to expand...

I'm sure you can identify with this . . .

I got to the ICU on Tuesday this week only to be called almost in a panic by one of my cardiology colleagues about a patient that was crumping and fast. The guy had a sick, sick heart, but my homie had decided this "CLEARLY" (heh) wasn't the man's problem and he probably needed my services and fast. I'm taking a quick look at the guy and his JACKED up labs and his JACKED up vital signs and his JACKED up poor old guy "I'm trying to die here face" and I'm thinking . . .

. . .

. . .

****. I have zero clue what is going on here.

*cues the muted trombones and rimshot*

The moral of the story: You won't always know, sometimes not for a long time, and sometimes not until there is an autopsy (unfortunately). I did however, save that guys life even without knowing exactly what was wrong at the time by doing what we do and treating the physiology with first principles in the absence clear diagnosis. And, as I'm sure you'd agree . . . THIS is why folks are in training. So if you don't know what to do it's because you're not supposed to yet, but you will, and sometimes, you simply won't know exactly what is going on at all with a pateint, especially in the ICU, even as an attending.

I think it's fair to say one week in . . . folks needs to cut themselves a whole lotta slack.
 
jdh71 said:
I'm sure you can identify with this . . .

I got to the ICU on Tuesday this week only to be called almost in a panic by one of my cardiology colleagues about a patient that was crumping and fast. The guy had a sick, sick heart, but my homie had decided this "CLEARLY" (heh) wasn't the man's problem and he probably needed my services and fast. I'm taking a quick look at the guy and his JACKED up labs and his JACKED up vital signs and his JACKED up poor old guy "I'm trying to die here face" and I'm thinking . . .

. . .

. . .

****. I have zero clue what is going on here.

*cues the muted trombones and rimshot*

The moral of the story: You won't always know, sometimes not for a long time, and sometimes not until there is an autopsy (unfortunately). I did however, save that guys life even without knowing exactly what was wrong at the time by doing what we do and treating the physiology with first principles in the absence clear diagnosis. And, as I'm sure you'd agree . . . THIS is why folks are in training. So if you don't know what to do it's because you're not supposed to yet, but you will, and sometimes, you simply won't know exactly what is going on at all with a pateint, especially in the ICU, even as an attending.

I think it's fair to say one week in . . . folks needs to cut themselves a whole lotta slack.
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And for future reference (if you werent aware), JDH is a fellowship trained Pulmonary-Critical Care physician. Six full years of training (plus some odd amount of practice) ahead of the OP. It happens.
 
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I started on micu as well in a different EMR, admitting every 3 days to every other day with 40-50 patients between 4 teams. Figure out a system for gathering data, get there early and do it quickly, don't worry about perfecting your notes, make folders for common labs etc, get info from nurses at shift change, and just generally try to be pleasant to work with. 1 year later you'll look back and realize how far you came.
 
MICU is a tough one to start with and nobody (seriously....nobody) expects you to hit the floor running in the MICU and have perfect plans or perform procedures right and left. The amount of numbers and information to gather in the morning is huge and you just have to find a systematic and efficient way that works for you (you can make a print-out template and just fill it in while pre-rounding). Generally speaking, learning how to formulate an ICU plan is not a job for an intern in July, but you will definitely get better by the end of the month. I wouldn't worry much about procedures for now. As mentioned many times above, please talk to the nurses and RTs before shift change because they know the patient best and they know why changes were made to the vent, sedation, meds, lines ...etc overnight.
interns who didn't freak out in July scared the s*** out of me as a senior resident because I knew they were doing something wrong and not asking me.
It will get better from here...you will look back at this and laugh... until your first month of fellowship.. then you freak out again
 
visari said:
It will get better from here...you will look back at this and laugh... until your first month of fellowship.. then you freak out again
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On Tuesday, I was the senior in the CCU adjusting IABP settings and withdrawing care on a 25yo who trashed her transplanted heart and we couldn't save. On Wednesday, I was the first call on a new acute leukemic in the ED with tumor lysis and got to tell a 42yo new dad that he had metastatic pancreatic cancer and likely wouldn't see his baby's first birthday.

Same s***, different specialty.
 
Nivakia said:
Your problems are really small

1. Breaking duty hours? I think you need to think about this comment before discussing it further.
2. Procedures? generally irrelevant in the eyes of the PD unless you actually want to do an ICU fellowship
3. On Rounds: Only your assessment and plans show how smart you are anyways, so formulate it the day before. Dont waste time presenting useless history and physical or labs. If you want to sound smart, present your plan first, and when the attending questions why, then you bring up pertinent history physical and labs.
Click to expand...

I respectively disagree with your post.

1. Breaking duty hours - we've all done it as residents (and not just in the MICU). Medicine isn't a clock in, clock out profession. And beginning interns are really inefficient so will take longer to do stuff that a May/June intern. And except outside NY, it's not a law (and 80 hrs can be averaged over 4 weeks). We should try to abide by the rules, but to not talk about it (or admit that we break them) only encourages new trainees to feel guilty (or think they're alone in doing this).

2. Procedures - don't worry about it at this point. There's enough on your plate and you'll get enough practice/shots as time flies. And depending on your career goal (Pulm/CCM, GI, Cards, Heme/Onc, Rheum, Hospitalist), you may not be doing procedures in your career. Some seniors/fellows/attendings are better at teaching procedures than others. You just need the right "teacher". (and some patient are more difficult to do procedures than others)

3. This is the ICU - you can't formulate a plan the day before. Your plan will likely change in the afternoon compare to the morning when new data are known (and you see patient's response to intervention). You're dealing with multi-systems involvement with acute physiologic changes in unstable patients (who most likely also have chronic medical issues).

And if you present your plan first to me on rounds before going over subjective/objective/physical assessment, as you suggested, I will pull you aside and ask that you work on organizing your thoughts and presenting skills. I want to know if you know what's going on with the patient, if you know the relevant data on the patient, the relevant physical exam, that you've seen the imaging studies (not just the report but actually LOOK at the imaging studies) and that based on the above, you've formulated a reasonable plan that you synthesized based on current information.


jdh71 said:
I'm sure you can identify with this . . .

I got to the ICU on Tuesday this week only to be called almost in a panic by one of my cardiology colleagues about a patient that was crumping and fast. The guy had a sick, sick heart, but my homie had decided this "CLEARLY" (heh) wasn't the man's problem and he probably needed my services and fast. I'm taking a quick look at the guy and his JACKED up labs and his JACKED up vital signs and his JACKED up poor old guy "I'm trying to die here face" and I'm thinking . . .
Click to expand...

Yeah, throw the kitchen sink at the patient ... and if he lives, take credit. If he doesn't, well, you tried everything (and then some). And we do this while trying to convince heme/onc that telling the family that "maybe one more round of chemotherapy might help" might not be appropriate for someone in multisystem organ failure
 
group_theory said:
And we do this while trying to convince heme/onc that telling the family that "maybe one more round of chemotherapy might help" might not be appropriate for someone in multisystem organ failure
Click to expand...

Says a man (or woman) that has obviously knows what they're talking about.
 
Nivakia said:
Your problems are really small

3. On Rounds: Only your assessment and plans show how smart you are anyways, so formulate it the day before. Dont waste time presenting useless history and physical or labs. If you want to sound smart, present your plan first, and when the attending questions why, then you bring up pertinent history physical and labs.
Click to expand...

Unless your icu is not all that sick, you probably can't formulate a full plan the day before.

Your job in the icu as the intern early in the year is to present all pertinent stuff so that your attending can set the plan. If you formulate a plan it's probably wrong... And that's expected at this point in the year

Know how they want you to present-
1) is it system based (ie all overnight events for cards, all vitals pertinent for cards, all physical exam for cards, cards plan- then on to pulm)
2) is it standard overnight events, exam, imaging them problem based assessment and plan?

This is a process. As others have said, if you were efficient and knew everything you wouldn't be a starting intern. Know that everyone feels the way you do early in the year. If you didn't feel out of sorts it would be even more worrisome. Stick in there. It will get better by about 2nd year.
 
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Instatewaiter said:
Know how they want you to present-
1) is it system based (ie all overnight events for cards, all vitals pertinent for cards, all physical exam for cards, cards plan- then on to pulm)
2) is it standard overnight events, exam, imaging them problem based assessment and plan?
Click to expand...
There's always going to be some system pertinent overlap, so won't a system based approach right from overnight events become a little redundant?
 
as everyone has already stated, it gets easier. your job is to let your senior know what's going on (ie pages you are getting) and doing what you're told.
 
ICU early in training just sucks.

The ONE time I recall breaking down a little during training was my first night on call in the CCU, which came early. I think I had a month of floors, and two weeks of night float first. My GF broke up with me the night before my 24 hr shift and I didn't get any sleep. I had an awesome junior resident with me keeping an eye on everything, but I still felt the weight of the world. I had no idea what was important to write in notes on these patients, which had to be hand written. Keeping up with what was happening to them all was even harder. Knowing I would somehow have to present these cases on rounds terrified me. The last straw came with a patient who had been transferred in coding. I was at a total loss to explain all the strange non-physiological lab values and what we might do with them. Thankfully the attending (who seemed very scary at the time) went easy on me at rounds. That was a tough night.

The worst feeling I recall from internship was feeling so incompetent compared to those around me. Something no one talks about is how everyone above your pay grade seems to have their own idea of what is "relevant" in a case. Reading minds is difficult, so it's easy to feel like you have to know everything and have it on instant recall. Since that is really hard to do, especially early on (were the platelets 257 or 194????), I would focus on the patient's story and presenting it well. Practice telling patient stories at home so you start to build a framework for ICU cases. If you don't understand the patient's story, say that. No one can fault you for not being an ICU whiz kid as an intern, but they will judge for looking unprepared, or worse, not knowing your limits. One easy way to score points is to be well read and be able to answer pimp questions well on rounds.
 
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Are what you guys saying pertaining to icu as an intern only or being an intern in general? Because I feel like **** right now and I'm on gen med
 
JP2740 said:
Are what you guys saying pertaining to icu as an intern only or being an intern in general? Because I feel like **** right now and I'm on gen med
Click to expand...

Generalize all you want from my post. The concepts are the same on the floor, there's just so much more data to crunch on ICU patients, as well as the seriousness that goes along with ICU level problems.

Hang in there, eventually all rotations come to an end. Embrace the suck, as the military recruits say. Once day you'll look back on this year with good memories.
 
JP2740 said:
Are what you guys saying pertaining to icu as an intern only or being an intern in general? Because I feel like **** right now and I'm on gen med
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The first (3?) month(s) suck as an intern, no matter what you're doing. I went from ICU to Inpatient Geri/SNF to Hem/Onc my intern year. About halfway through my Hem/Onc rotation I finally felt like I could find my ass with both hands at least 3 days a week. It got better from there.

Incidentally, I now work a 0.75 FTE job which equates to 3 days a week. I'm sure this doesn't have anything to do with my experience as an intern, but perhaps it does.
 
Was working county hospital MICU rotation on 2nd month of internship and I think on the 2nd call of the rotation, came pretty damn close to wanting to hide in a janitor closet
 
gutonc said:
The first (3?) month(s) suck as an intern, no matter what you're doing. I went from ICU to Inpatient Geri/SNF to Hem/Onc my intern year. About halfway through my Hem/Onc rotation I finally felt like I could find my ass with both hands at least 3 days a week. It got better from there.

Incidentally, I now work a 0.75 FTE job which equates to 3 days a week. I'm sure this doesn't have anything to do with my experience as an intern, but perhaps it does.
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Thanks man. I'm sitting in my car reading this before going in and it helps. I'll post more later.
 
obiwan said:
Was working county hospital MICU rotation on 2nd month of internship and I think on the 2nd call of the rotation, came pretty damn close to wanting to hide in a janitor closet
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mine was wanting to crawl under the desk...occasionally still have that feeling...
 
I spent the first month of my intern year in the CCU. I worked late, and felt like crap when I got things wrong on rounds. Thankfully, my residents backed me up, and my attendings and fellows fully understood that this was my first month of being a real practicing doctor. It gets better.

OP, this is COMPLETELY NORMAL. You are doing fine. You are going to be fine. You may think you're the only one who feels terrible and feels like he doesn't know anything, but neither do your compatriot interns either 😉.
 
This is normal. Don't worry. I was like you when I started. Now I am a Hospitalist.
 
Hang in there, buddy! Suffering is part of the learning process, it's a sign you're learning a s*!t-ton!

"To those human beings who are of any concern to me I wish suffering, desolation, sickness, ill-treatment, indignities—I wish that they should not remain unfamiliar with profound self-contempt, the torture of self-mistrust, the wretchedness of the vanquished: I have no pity for them, because I wish them the only thing that can prove today whether one is worth anything or not—that one endures.” Nietzsche
 
Oh my god, I'm feeling the exact same way. ICU is so much harder than it was as a student, I don't know how my interns made it look so easy back then.
 
If you're a MICU intern, nobody from the attending to the janitor expects you to know anything (sorry... it's true)

It would be great to learn how to formulate some detailed critical care management plans but frankly that is what your resident is supposed to be doing. Your mission, should you choose to accept it, is to 1) learn how to gather a ton of data and communicate it to another person in a semi-coherent manner, and 2) learn the basics of keeping somebody alive at first contact when they are trying to crump on you.

These are skills that you will be glad to have on your floor months, ER month, night float, etc. Try to learn how to assess volume status, scary electrolyte abnormalities, respiratory distress, etc in a somewhat rapid manner and how to react. You can worry about the long-term management of their underlying problems later, once you're comfortable with the day to day grind of keeping them alive


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Psai said:
Oh my god, I'm feeling the exact same way. ICU is so much harder than it was as a student, I don't know how my interns made it look so easy back then.
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I don't know, my ICU interns as a student did not try to pretend they were okay. "Oh dear Lord please let me not kill anyone tonight" was the refrain of one particular intern starting each of the overnight shifts I was on.
 
clausewitz2 said:
I don't know, my ICU interns as a student did not try to pretend they were okay. "Oh dear Lord please let me not kill anyone tonight" was the refrain of one particular intern starting each of the overnight shifts I was on.
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Haha, man I feel that way as an upper level. The MICU isn't a place to mess around and people can die quick. Being on your toes and realizing even as an upper level that you aren't some kind of expert is a good way to go.
 
Id say it us more alarming if junior (or senior) residents are super cocky in the unit. I was pretty excited as a PGY 1 on ICU because I had so much backup/support. Way more terrified as a senior given that there were nights where I was the most senior in house person and had to make some difficult calls. Sure the fellow was a phone call away but the real time, acute stuff was all you.
 
Starting nights on the cardiology ward service tonight as an intern. A prelim nonetheless. The fellow is supposedly "just a call away", but I'm feeling very uneasy not being comfortable at all with this subject matter and being the ultimate responsible one there. Would love the safety net of having an upper level there with me but that's not possible. Ccu patients that are very sick and a list that's approaching 30 pts. It's almost too much. One week till freedom and it cannot come soon enough.


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