I'm a nervous wreck about intern year, any keys to a successful intern year?

[Sushi Chef]

It just seems so surreal after using 4th year doing everything one could imagine before starting internship in a month or so. Any survival tips for intern year for general surgery?

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[JayDoc06]

take things one day at a time and always keep your chief informed, always.

 

[sponch]

um, the job is real easy. just write everything down and do what your chief tells you to do. be available, affable, and trainable. bottom line -- just get things done. people appreciate a service that runs tight and smoothly. take care of issues that arise so your seniors don't have to even hear about them.

 

[surgical06]

i'm just finishing my intern year, last year i posted a similar question and was frustrated by general comments like keep the chief in the know, or run a tight ship, general instructions will get u nothing but yelled at, don't be afraid to ask specifics if u don't know. i learned the hard way..lol

1) while it will feel like u r on your own when u first start, there are several people watching you , your orders, patient evaluations. including nurses and if u r electronic, pharmacist. you will make mistakes, its ok. some nurses like to belittle u for mistakes, its ok, they r bitter and you are learning.
2) the major job for an intern is to be able to "make aware" your senior residents. while they r in the OR or chief room, wherever they hide. lol..so, change in clinical status; lab results, cultures, test to order ; CT scans, fistulagrams, small bowel follow thru ect. order and f/u these results several times a day, it will become annoying. this is what BE THE EYES AND EARS or the team means, which suks.

yes we r secretaries; sorry. yes i am bitter...lol

3. as far as your job, i.e what u signed up for. you will get to operate occasionally, some months pretty often. get in the habit of watchin the OR schedule and knowing when u have a case or ask your junior/senior which cases r yours.
4. most of your calls will b for pain, fever, hypertensive, low uop. b/f u start, ask the current intern what they use for pain, and how they give it. 1st line pill, stronger pill if it doesn't go away. 1st line IV, second line IV.

until u get comfortable, i would bump up any hypotension, low uop, fever in post op pt, low sats, arrythmia (except the famous doctor pt had 8 pvc's on strip) from the tele floor. tell them to go fly a kite, but do take a look at their electrolytes, make sure their K isn't low.

it took me 2hrs to catch a PE my first month on service. classic pt too. pelvic fracture, bedridden, diaphoretic, with a cervical halo on. what the @!$#% was i thinking. i was thinking what can i do to make his complaint of pain go away, instead of asking what was going on w/ him. so from that point on, i made myself write down the pts chief complaint and syptoms if any, comprise a differential. sounds corny as hell, like that dumb clinical skills test; but u would be suprised and others will be impressed by your proposed differential/workup; and soon they will trust u . i don't write down stuff anymore but i do sit at the patietns door and review it in my head after i've seen thems. .

and when **** hits the fan and everyone is running in and out of the room, always remember calm heads prevail. plan a routine for walking into codes if u r first there; bag them, EXPOSE/examine the chest, slap defibrilator pads on them, by that time help should be there. if u want to run the codes there is a great book; Management of the Coding Patient, excellent differential and management..

at night when u r solo, know who is in house that either is supposed to or can back u up. i was covering an terribly unstalbe pediatric burn one night, i went to the peds floor, talked to the pediatric intensivist and told her, i may call u. didn't know her, she didn't know the patient, but help is help

at my institution there is always a trauma chief and attending in house; while i never had to, i was prepared to page them overhead if need be.

i think that should have u covered, sorry if i left anything out.




.

 

[surgical06]

i'm

 

[jubb]

Here is a nice thread on this topic. There is another I remember but can't find right now.

http://forums.studentdoctor.net/showthread.php?t=507609

 

[ESU_MD]

do what you are told

know stuff before others on your team know it

come earlier, stay later

always write the postop note and orders for your seniors (if no students are around)

don't complain about being tired, not getting to go home early for your wife's, grandmom's birthday, etc..- no one cares

and above all, never try to use the 80hr "rules" as an excuse to get out of doing something that you should do, even if it means staying a little late sometimes. (if you are staying 120hrs a week, then thats a problem)

good luck

 

[tussy]

Being that i'm now a PGY7, i've seen many a PGY1 come up the ranks behind me. Here is what i expect from a PGY1

- know your limits and ask for help when you're in over your head
- keep your seniors informed of changes in patients' status, even if you've got it all under control. However, as you're asking for help you should also be starting the appropriate exam, resuscitation, investigations, etc. and be prepared to give your senior all the appropriate info when you call them.
- read around your patients
- know your patients inside and out
- have a good attitude and be a team player.
- do your best and realize that residency is 5+ years for a reason and you can't be expected to know it all the first day you start

 

[filter07]

1. bend over here it comes
2. write everything down
3. your differential is a) what can kill/harm b) what's most common c) ask upper level.
4. social work is your work, your task is to find out how to discharge someone. it's sort of like a puzzle in a way. at least that's how i think of it to make my life seem less mundane.
5. you are the one doing the job that nobody else wants to do. that includes secretaries, social workers, PAs, NPs, nurses, even medical students... EVERYONE'S job is your job. get used to it early and make peace with it.
6. find out what's important to remember and what can be looked up. you don't have to know the whole BMP or LFT but remember what the Cr is on someone with ARF, remember the dbili on someone with cholecystitis, ESR on someone who just had surgery... just kidding on the last one
7. you never get in any real trouble for calling too often. however not calling can really get you into big trouble. so when in doubt, call your senior residents.
8. confidence goes a long way. just appearing confident is enough
9. nobody dies in a split second, so chill out when something major happens. you always have more time to think and act, even on someone who is "crashing" (but not necessarily for a nap or a coffee break)
10. you'll hit the wall sometime between october and january. you're not alone.

 

[geekgirl]

1. bend over here it comes
2. write everything down
3. your differential is a) what can kill/harm b) what's most common c) ask upper level.
4. social work is your work, your task is to find out how to discharge someone. it's sort of like a puzzle in a way. at least that's how i think of it to make my life seem less mundane.
5. you are the one doing the job that nobody else wants to do. that includes secretaries, social workers, PAs, NPs, nurses, even medical students... EVERYONE'S job is your job. get used to it early and make peace with it.
6. find out what's important to remember and what can be looked up. you don't have to know the whole BMP or LFT but remember what the Cr is on someone with ARF, remember the dbili on someone with cholecystitis, ESR on someone who just had surgery... just kidding on the last one
7. you never get in any real trouble for calling too often. however not calling can really get you into big trouble. so when in doubt, call your senior residents.
8. confidence goes a long way. just appearing confident is enough
9. nobody dies in a split second, so chill out when something major happens. you always have more time to think and act, even on someone who is "crashing" (but not necessarily for a nap or a coffee break)
10. you'll hit the wall sometime between october and january. you're not alone.

wise words.

i think the interns i view as weak have the wrong attitude. it's the "this is not the job i signed on to do" attitude. i applaud the above post. your job is to do ALL jobs, even when those assigned to those ****ty little jobs won't do them. no whining, no temper tantrums. just get **** done so he team can continue and the operations can occur.

as cheesy as it sounds, remind yourself that it is about the patient at all times. not you. no ego. no tired. these people are your moms and dads or whomever. they are not objects. so give them good care.

 

[SLUser11]

It just seems so surreal after using 4th year doing everything one could imagine before starting internship in a month or so. Any survival tips for intern year for general surgery?

My advice would be to bring a change of socks and underwear for your call nights.

Then again, I have to admit that I don't use my own advice.......

 

[Statasap]

The only rule is:

1) Endure and survive the year-- and do whatever you have to do to achieve this.

This may mean doing jobs everybody else doesn't want to do but it will also mean telling other people "uhh, no, i'm busy now and i won't be doing that random task". It means not whining and complaining when unkind ears are around but it will also mean whining and complaining to your buddies and anybody else who will listen. You sometimes have to look at intern year as being a sort of mini-war where (almost) everybody is against you and you're just trying to survive (along with your patients, of course). Yes, it's true, other people won't care about you and whether you're tired or not, sick or not, whether you have to go to your own "surprise" birthday party or not-- but guess what-- YOU should care! And just like any war, you'll need to enlist as many people as you can on your side- fellow interns, family, spouse, girlfriend/boyfriend, drinking buddies, nurses, patients, pizza delivery guy-- you'll need the support.

 

[jubb]

This is a quote from one of the other threads I remember as being good advice.

Everyone stresses to death about starting internship. Those who don't get shocked rudely. Your first month you are going to lean heavily on your senior residents. To them it will seem like you can barely roll over, let alone crawl or walk.

It's July, they should know and expect it. My dad has a saying: Frogs forget what it's like to be tadpoles.

If you have time, read Charles Bosk's 'Forgive and Remember.' It's his sociology PhD thesis: he studied surgery teams at the University of Chicago (disguised in the book) like he was studying a primitive tribe. He focuses on punishment, team building, ethics, errors. Much of it remains true to this day. It's a very thin book.

He describes:
Technical errors - Forgivable if recognized early and rectified.
Judgement errors - Same
Ethical/moral errors - Not forgivable. Making a technical error, such letting go of the wire during a central line, have it disappear into the patient, then not telling anyone out of fear and leaving it in the patient, then having the team discover it two days later on CXR, is conversion of a technical error to an ethical error, is bad. That resident is now working in a flower shop, not because they messed up with the wire, but because of how they handled that situation.

One of the doctors in it, rumored to be Dr. George Block, is quoted as saying: I want from a resident these three things: Availability, affability, and ability, in that order.

Things I remember (I just graduated last June):

Reputations snowball. People categorize interns into 'strong' and 'weak.'

Strong: You'll never go wrong if you go to see the patient.

Strong: Write everything down. You will probably round and be given 3-5 thing to do on every patient. Write it down. You will not remember. Nobody does. Come up with a system, a patient list with check boxes every day, something, anything. If your chief sees you writing down all the tasks every AM, and you forget something, it'll easier to be forgiven than if he or she never sees you write anything down.

Strong: Learn early how to prioritize. A patient being kept waiting till 4PM for discharge orders when you decided on AM rounds to d/c, while the patient not going home today got his staples out and steri-strips on in the AM, not good. If you're having trouble, check with the chief. I used to tell my 'terns, if you get three things done before 10AM, they should be...and I want to know this CT result by 1PM... soon, I didn't have to, they just knew.

Strong: Action, reaction. If you do something, follow up on it. Don't bolus a liter for oliguria then 8 hours later find out the urine out put didn't pickup and now the patient is anuric. Don't write orders for 2 units on the patient with cardiac issues and four hours later get called for hypoxia and wet crackles. Don't be asked on afternoon rounds, so what did that CT show? And say uh... and find out radiology bumped you to the end of the line and it may not even get done today now.

Strong: Don't procrastinate. You don't want to get pulled off service because you have 100 discharge summaries waiting for you in medical records.

Weak: Your body and emotions are your own worst enemy. Your desire to eat lunch, rack for a few more minutes, letting your hatred of a particular nurse cloud your judgement when they call you with 'this guy doesn't look right' is where you will get burned, not from lack of intelligence or even lack of knowledge.

Weak: Continual conflicts with support staff. Getting stressed and yelling at the nurses doesn't help. It just makes the rest of the rotation harder and your attendings will hear about it. In many cases, the attendings have known that nurse for much longer than they have known you.

Strong: There is a difference between efficiency and cutting corners. One will get you time to go to the operating room and get you home at a reasonable hour. The other may get you home in the middle of the day, without a job.

Strong: The enthusiastic and cheerful resident tends to have an easier time than the sullen, complaining shirker who the nurses always see is calling from the call room: you do not want to graduate and at your Chief Roast win the 'Napa Valley Whine' award.

Strong: Your chief will only look as good as you let him or her look.
Strong: corollary: never blame anyone else, accept responsibility and also put forward a plan for how to fix the mistake.

Weak: Constant excuses and explanations for why something didn't get done.

Strong: Your only allies are your fellow interns. Don't screw them over. Build a team and syngergy can result. Every once in awhile a program seems to get someone who thinks they can get out a little earlier, make their own life a little easier at the expense of their co-residents. You work together too closely and for too long for people not to figure out pretty fast that someone smells, and not long after, who the stinker is. Life for that person tends to get considerably harder after that.

We used to fight over sign out before the days of 80 hours, and when we had Q2-3 call.

Sign out to me!
No! I'll be done with everything in another hour.
Just gimme your list! I'm here all night anyway!
No, you've got enough to do and I'm almost done!

Turns out our chairman was around the corner, med student stumbled into the chairman and was like, the boss is right around the corner listening to you guys. A week later, we were out having drinks at a local hotel lounge, someone said they thought they saw the chairman. Later, we were mystified when we were told our tab was already covered. (8 residents and s/o's, it was a big tab). When we asked who?... they showed us the receipt.

People appreciate what you do. They just don't tell you 99% of the time. It's the last bit of the old school left, IMO.

I had a code called on a patient who was accidentally given too much IV beta blocker. Ran there, gave her atropine, got her to unit, no lasting adverse events. Attending slapped me on the back and I feel good. Later that day, he yell at me about something and asks if I've done anything at all to advance the care of his patients that day!!??! So I mention that earlier incident. He says, 'That was five minutes ago. What have you done lately!?' then he laughed and chilled out.

So my final advice to you is: Let it roll off, like water off a duck's back.

A person who climbed the highest peaks on each continent did Everest last, and said the last stretch of Everest was the hardest to keep going up. You are on that last stretch. Don't give up now, be confident but not arrogant, work hard and care, and you'll be fine.

 

[tussy]

My only other advice is to make friends with the nurses. It sometimes feels like they are out to get you and are the enemy, but they can be a real advocate for you. I remember a particularly bad week when i was an intern, doing a run of 1 in 2 call on a busy service and it felt like nothing was going well. One of my chief residents chewed me out for something and i was almost in tears. The charge nurse witnessed it and after the chief left, the charge nurse pulled me into her office to tell me that i was a good intern and good doctor and that intern year is temporary and I'll get thru it. Then she made me tea! It was really sweet. The nurses on that ward treated me like gold for the next 5 years of my residency!!!

 

[njbmd]

My advice for intern year:

• Realize that it will be worse that you imagined but better than you expected.
• Time is both your friend and your enemy. Learn how to get things done early and efficiently.
• Read, read and read some more. Make yourself read at least 30 minutes daily. When ABSITE comes along, you will be happy that you did this.
• Write everything down and check off things as you go.
• There is nothing like the "personal touch". Call your consultants early and thank them.
• Follow-up on any orders that you write. If it's happening to your patient, you have to know about it.
• Learn to read the anesthesia notes. You can head off some problems if you have a handle on where you patient is fluid-wise and how they did during the case.
• Troll for every case that you can scrub. Given a choice between sleep and operating, I always chose to operate.
• Be nice to everyone even when you are tired, dehydrated and cranky. Just remember, you chose this profession and internship is part of that choice. You are living your dream so enjoy it.

 

[ESU_MD]

My only other advice is to make friends with the nurses.

I have to disagree with this comment.

One of the first things you need to realize in doctor life-

nurses ARE NOT your friends

They have a different role in the hospital- essentially they have no responsibilty for their actions, and will blame you for things. I have seen too many residents get burned by nurses they are too friendly with- put in orders without telling them, not calling when they should, etc..

I am not advocating being a total jerk, you can be professional without crossing the line.

A good resident will always have some negative comments on their nursing
"360" evaluations. Nurses who get called out for not doing their jobs will give residents bad "evals" (like it matters what they think about us)

Be wary of residents who the nurses love, they are puppets.

 

[San_Juan_Sun]

I have to disagree with this comment.

One of the first things you need to realize in doctor life-

nurses ARE NOT your friends

They have a different role in the hospital- essentially they have no responsibilty for their actions, and will blame you for things. I have seen too many residents get burned by nurses they are too friendly with- put in orders without telling them, not calling when they should, etc..

I am not advocating being a total jerk, you can be professional without crossing the line.

A good resident will always have some negative comments on their nursing
"360" evaluations. Nurses who get called out for not doing their jobs will give residents bad "evals" (like it matters what they think about us)

Be wary of residents who the nurses love, they are puppets.

I call this the Siegfried and Roy Principle. The huge tiger may look fuzzy and tame. It may let you run it through hoops of fire a million times. It may pose with you in your family pictures. And it may just bite your face off when you aren't expecting it.

I believe in being nice and friendly with the nurses. But don't ever expect them to cover for you or give you a courtesy of preferential treatment. They may do it a million times, but the one time they don't, it can hurt you badly, or even worse, the patient.

 

[geekgirl]

i disagree with the above comments.

doctors and nurses have different roles. different jobs. different job descriptions. sure i know residents who have been screwed by nurses. and vice versa. (obviously, ignoring the grey's anatomy type references here).

i think it's good to have a good working relationship with the nurses. but understand that their priorities and ours are different. that can by symbiotic or antagonistic, depending on your management of the situation. and, of course, unpredictable variables of personality and skill set. i have friends i go out with who are RNs. and i hear their bitches, just like we all bitch.

my reconciliation of minds is that our jobs are different. if we treat w respect and appreciate why some of them call at 2am with bull**** (i.e. it is midshift for them and they forget we've been on for 24hrs) then it all goes well. but you need not be their best friend to work well with them. but be respectful. they can hammer page you all night if they don't like you (and they will) or they can give you a peaceful few hrs of sleep if they like you. i prefer the latter....

 

[Winged Scapula]

I'm sorry but if I can remember that the rads residents are in conference daily from 12-1, that Cards consults switch at 0800, that Anesthesia is in conference Thursdays until 0845, that Grand Rounds is the 3rd Thursday of the month, etc. then the night shift nurses should be capable of figuring out that 0200 is NOT the middle of resident's shift and that they have been up nearly 24 hrs.

 

[Blade28]

At the very least, nurses should learn that we don't work "8s" or "12s."

 

[sunflower79]

nice post/quote by jubb.

Also:
When you get called about a patient in pain, don't automatically write it off by ordering more narcotics from the comfort of your own bed.

Stay calm. When a patient is crashing, call your senior and stick to the ABCs.

The progression of learning will be something like this, if I have this right:
first you don't know that you don't know (scariest),
then you know that you don't know,
then you know that you know,
then you don't know that you know (things become automatic).

 

[Blade28]

Early on, you should probably go physically see every patient you get called about - until you develop your own approach and comfort level.

 

[kaos]

At the very least, nurses should learn that we don't work "8s" or "12s."

It really surprises me how many nurses honestly don't know that.

 

[opr8n]

1. dont complain, your life will svck, just accept that
2. work hard, its only one year
3. ALWAYS communicate with your seniors and/or attendings, dont do anything major without asking them first
4. Study whenever you can
5. remember EVERYTHING is a learning experience, even if you arent doing anything, scrubbing a rare open common bile duct explor as the 10th assistant is still helpful

 

[opr8n]

and another thing
dont complain about working 85 or 90 hours

b/c as much as people "say" that they are in favor of the 80 hour rule
when it comes to enforcing it, you are just a complainer

sad, but true

 

[ExtraCrispy]

nice post/quote by jubb.

Also:
When you get called about a patient in pain, don't automatically write it off by ordering more narcotics from the comfort of your own bed.
.

This is absolutely true, and should be the rule for ANY patient complaint, no matter how benign it seems.

One of the most common pages I received as an intern was the following:
"Pt in 7-20A seems anxious. Can I have an order for Ativan?"

If I'd just written the order, the nurse would have been satisfied... but anxiety in a post-op patient is often not a benign thing. In one particular case, the patient for whom they were requesting Ativan had a known DVT; when I ran to see her (and checked her VITALS...this nurse was not one of the best I've seen), she was satting 74% and had a HR of 130. Guess what caused her "anxiety"? I can assure you, Ativan wouldn't have fixed the problem.

Especially when you're starting out, and you don't know when a problem is real or not, see every patient for whom you're called. It's much, much better to take the few minutes and walk over, than to ignore it and really hurt someone. Over time, you'll be able to field more from the phone, but when you start, be hypervigilant.

 

[Blade28]

In general we never give Ativan on the floors here.

 

[cilia2007]

Speaking as someone whose contract was not renewed after intern year...

It's good to freak out and offer to go over and above to fix stuff when you screw up (i.e., you forgot to order blood/antibiotics/you name it: offer to go to blood bank/pharmacy/OR supply and get it)...If you have a more "relaxed" personality than the average intern, try to make it obvious to everyone that you're very sorry/you've learned/you won't do it again when you screw up. Say something like, "OK, I really screwed that up and I'm sorry. What should I take from this to make sure this won't happen again?" (although in many cases it should be obvious).

ALWAYS introduce yourself to everyone you're working with; it's MUCH easier to ask them for things/favors if you know their names. It's also easier for them to correct you (yes, I'm thinking of OR nurses here...)

Don't hum in the OR. Although that might just be your favorite song on, I guarantee you that humming will annoy people, and they might tell your program director instead of you.

Some advice I got regarding focus, which may seem obvious to some, but not to others, is that the best residents one particular attending had worked with were those who were so focused on the surgery being performed (whether they were doing more than retracting or not) that they barely heard her when she asked them questions. Conversely, though, if you're retracting, you'd better be making sure your retraction is at a constant angle/tension, even while you're concentrating on what the operating surgeon is doing...

Especially, all of the above about learning to multitask and write things down (highlighters and multicolored pens are an intern's friend).

And also, the snowballing reputation thing is EXTREMELY true, at least, at my former program.

And if you just happen to be a phlebotomy ace ('cause we all are, right?), your night float months will go much more smoothly. Barring that, lean quickly which nurses are really good at starting lines/getting labs, so that you can then ask them to do you favors when you're working (even on other floors) with nurses who aren't so good.

Pay attention to how your co-interns act (as much as you can, given that you really won't work with them that much); try to fit in as much as possible.

And perhaps most important--this will vary depending on the culture of the program, but never ask an attending a question you don't already know the answer to (i.e., only ask them questions that show you've been reading), unless the health of the patient is immediately at stake. "Learning" questions are for your senior residents and fellows. This isn't to say don't ask questions, but be judicious about the ones you ask attendings. I suppose this could be summed up as, "keep your mouth shut". Look it up, then ask about it.

All posted in the spirit of "don't let what happened to me happen to you!"

 

[Arch Guillotti]

To the above poster I am curious what you are doing now. Best wishes.

Oh and I completely agree with the snowball thing. The best thing to do is fly low under the radar, no matter what firld you are in. Attendings in the OR gossip like a bunch of little high school girls.

 

[cilia2007]

Had a research job lined up, got offered a 2nd year prelim spot at another program in town (at the last minute). Had several other similar spots I could've pursued, but didn't want to sell house and move for something that would only last a year. It works out well, though, because even though I may still have to move at the end of the year, all PGY-3 spots are categorical.

Might still chuck it all and switch to anesthesia at the end of the year though!

I'm happy to correspond with anyone who might find themselves in a similar situation. There is life after (professional) failure.

 

[Blade28]

Just to clarify, you're doing prelim G Surg in the hopes of landing a PGY-3 spot at your current program next fall?

 

[cilia2007]

Or anywhere; I'm flexible...