Performing at the "level of an intern"?

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lockian

lockian

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What does this really mean? People who have gotten this as feedback, can you share your wisdom?
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4thQTHailMary said:
What is this, a humble brag? I mean honestly, what else could it mean besides exactly what it says?
Click to expand...

I think he's asking how to do it, after reading on SDN that it is expected or looked for (e.g. on audition rotations).

I'm wondering the same. How, particularly when autonomy and trust are limited on rotations, does one function at the level of an intern? What are some examples people have in mind that one should do this?
 
- Write your own notes. A lot of med students think their notes are not valuable and it's a waste of time because nobody will see them. It's good practice, but you need to do it efficiently. Sign off on progress notes within an hour of rounding, and sign off on H&Ps within an hour of seeing a patient. Because interns don't have the luxury of time like med students do. In your note, always include discharge criteria and disposition- shows you know the clinical endpoints. We use EPIC here, and I always send my notes to the attending and chief- helps for feedback, shows the team you are actually trying to functional at the level of the intern. Plus, if you do it early enough, it can help the resident taking care of the patient.
- Do not spend more than 30 minutes with a patient. It would be nice to spend hours with a patient, but you have to be efficient. If you want to carry the same # of patients an intern carries, you have to be efficient in evaluating patients, and that means knowing what questions matters, and what PE items are relevant. The point is not to ask or examine everything under the sun (a trap I fell into on my IM rotation).
- Write orders. I can pend orders in our hospital software for others to sign off, and this always seems to make residents happy since it means less work for them.
- Get stuff done. I notice this time and again. Interns and residents just sit there and complain about EVERYTHING that everyone else is not doing (i.e. the nurse didn't give the medication, the outside hospital didn't send the paperwork, the imaging wasn't done, lab reports haven't been uploaded, etc.). Don't fall into this trap. If you want something done, you have to do it yourself. If labs weren't uploaded, go down to the lab and ask for them. If the outside hospital hasn't send the paperwork, just keep calling them till they do. Do not wait for other people to do their job because that's valuable time you're wasting.
- If I am on outpatient, I call my patients as follow-up during my free time to make sure they got the labs/ imaging studies/ diagnostic studies the attending had ordered, and to see if they're following up on the plan. This way, when they come back, I know they've done what we've asked rather than being annoyed and wasting another 20 minute appointment repeating the plan.
- Always come up with your OWN plan. Super easy to just agree with the resident or harass him or her till they tell you what they're planing on doing, but part of being an intern is not relying on anyone else. Even if your plan is completely wrong (obviously it can't be absurd, but it doesn't have to be perfect), as long as you can defend it and show your thought process, nobody will fault you. This is one aspect I think students feel the most awkward about, but I try to put myself out there as much as I can now because it shows the attending you know what you're talking about, and can think on your own.

The best advice somebody ever gave me for third year was "be the hardest working person on the team." Hasn't failed so far.

Not sure if this obvious, or if this helps, but this is what I've gathered from third year in terms of how to be an intern.
 
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I got this comment for the first time, on my 2nd month of internal. It's just practice man, no real secret. The same things you hear from everyone (be quick to volunteer for nearly everything, pre-round on all your patients and know them better than anyone else, get your oral presentation skills down solid, present well thought out differentials and treatment options, write thorough notes on your patients every day, etc.) hold true...the more you do it, the more efficient you are with it and the more confident you are handling/presenting it. There is still a knowledge gap between me and the interns, but I notice it getting smaller with each rotation.

One practical bit of advice: I see most students around me still presenting every piece of info on morning rounds (i.e. complete CBC's and BMP's, even when they're all normal). When they present, it seem like everyone, besides them, is acutely aware that they're spitting off all these numbers that don't matter. They get tuned out. Present the pertinent positives and negatives of labs/tests/ROS/PE, a well thought out A&P, and NO MORE. Be prepared to offer any info you left out, but DON'T present a laundry list of normal findings. It makes it look like you don't know what's important and what's not.

Hope that offers some insight into what residents/attendings regard as "intern-level" functioning
 
Do all the above, but it's important to ask your chief on day one what they expect you to do. When doing away rotations (or "acting internships") it's more important that you be as helpful as possible and not get in their way rather than be an annoyance. You have to understand the role you play on the team and honestly having an "extra intern" on a floor that's accustomed to running well with one won't necessarily be better off. You need to complement their role and you should ask your seniors how this is best accomplished.

Note: This is coming from the perspective of someone who rotated on small surgical services that are used to only having one intern per team. It's different if your team has multiple interns.
 
If I was to write this for a medical student eval (which I have), its because:

-Strong work ethic. shows up promptly (before resident/attending ) sees every pt asked to - asking to help with new patients, never complains, always eager for more pts.
-Able to help the team without being overbearing/annoying. For example: help get lab results, help get imaging studies and their results. Contacting family members/ PMD for additional information
-have a range of knowledge that exceeds what is expected -for medical students this is often the APPLICATION of knowledge as opposed to a "collection of facts".
-Able to find subtle details on history and physical
-Able to form a well rounded differential diagnosis.
-do all the above in an friendly nonobnxious manner

One medical student really stood out to me and others. I wrote that "I wish I could have him start internship with us today, Inavaluable to the team, an asset to any program that he chooses to join." What did he do? Everything above.
 
Wow. Well said.

Would only add being aware of your physicality and body language. Be in the circle, not off to the side leaning against the wall. Have paper in hand and make notes on the plans for each patient so you can follow them up. Even if it isn't your patient, just looking engaged and taking notes looks much better than being a wallflower with your hands in your pockets. Never ever look at your phone in the hospital.

People above hit the major points already.
 
colbgw02 said:
Shouldn't be hard. Interns don't know ****.
Click to expand...

The only true statement in this thread.

Having a good work ethic, appearing engaged, and not being annoying have nothing to do with "preforming at an intern level."

All it means is that you're only a little bit less useless than normal.
 
Will you come give this talk to all of my students? I come in trying to teach every single day, but I get more and more aggravated as the day goes on and they show 0 initiative, independent thought, or that they're reading at home. The rare student who does come by and do this I revere as a god.



DrShazam said:
- Write your own notes. A lot of med students think their notes are not valuable and it's a waste of time because nobody will see them. It's good practice, but you need to do it efficiently. Sign off on progress notes within an hour of rounding, and sign off on H&Ps within an hour of seeing a patient. Because interns don't have the luxury of time like med students do. In your note, always include discharge criteria and disposition- shows you know the clinical endpoints. We use EPIC here, and I always send my notes to the attending and chief- helps for feedback, shows the team you are actually trying to functional at the level of the intern. Plus, if you do it early enough, it can help the resident taking care of the patient.
- Do not spend more than 30 minutes with a patient. It would be nice to spend hours with a patient, but you have to be efficient. If you want to carry the same # of patients an intern carries, you have to be efficient in evaluating patients, and that means knowing what questions matters, and what PE items are relevant. The point is not to ask or examine everything under the sun (a trap I fell into on my IM rotation).
- Write orders. I can pend orders in our hospital software for others to sign off, and this always seems to make residents happy since it means less work for them.
- Get stuff done. I notice this time and again. Interns and residents just sit there and complain about EVERYTHING that everyone else is not doing (i.e. the nurse didn't give the medication, the outside hospital didn't send the paperwork, the imaging wasn't done, lab reports haven't been uploaded, etc.). Don't fall into this trap. If you want something done, you have to do it yourself. If labs weren't uploaded, go down to the lab and ask for them. If the outside hospital hasn't send the paperwork, just keep calling them till they do. Do not wait for other people to do their job because that's valuable time you're wasting.
- If I am on outpatient, I call my patients as follow-up during my free time to make sure they got the labs/ imaging studies/ diagnostic studies the attending had ordered, and to see if they're following up on the plan. This way, when they come back, I know they've done what we've asked rather than being annoyed and wasting another 20 minute appointment repeating the plan.
- Always come up with your OWN plan. Super easy to just agree with the resident or harass him or her till they tell you what they're planing on doing, but part of being an intern is not relying on anyone else. Even if your plan is completely wrong (obviously it can't be absurd, but it doesn't have to be perfect), as long as you can defend it and show your thought process, nobody will fault you. This is one aspect I think students feel the most awkward about, but I try to put myself out there as much as I can now because it shows the attending you know what you're talking about, and can think on your own.

The best advice somebody ever gave me for third year was "be the hardest working person on the team." Hasn't failed so far.

Not sure if this obvious, or if this helps, but this is what I've gathered from third year in terms of how to be an intern.
Click to expand...
 
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styphon said:
If I was to write this for a medical student eval (which I have), its because:

-Strong work ethic. shows up promptly (before resident/attending ) sees every pt asked to - asking to help with new patients, never complains, always eager for more pts.
-Able to help the team without being overbearing/annoying. For example: help get lab results, help get imaging studies and their results. Contacting family members/ PMD for additional information
-have a range of knowledge that exceeds what is expected -for medical students this is often the APPLICATION of knowledge as opposed to a "collection of facts".
-Able to find subtle details on history and physical
-Able to form a well rounded differential diagnosis.
-do all the above in an friendly nonobnxious manner

One medical student really stood out to me and others. I wrote that "I wish I could have him start internship with us today, Inavaluable to the team, an asset to any program that he chooses to join." What did he do? Everything above.
Click to expand...
I second this. I did the things above, and it was mentioned in a couple of my evaluations that I performed at an intern level though I did not place orders and was not fast/efficient writing my progress notes.
 
The rotations where I received this feedback were the ones where I looked at all the jobs my intern was doing, from menial to complex, and just did as many of those as I was allowed. I'd split the patient list equally with the intern or interns, pre-round on my share of the patients, and write their notes for the day. I presented my patients in the morning, came up with my own plan, lined up everything I could in terms of their orders and labs (up to the point where they'd need to be cosigned), and wrote notes on all of them. I'd give my patient's nurses my pager number so I would be the first point of contact, and I would be the one on the phone calling consults, social workers, family members, and anyone else that needed to be contacted about my patient. Some mornings I'd take my intern's pager and field calls so she could go to the OR without feeling as stressed about leaving floor work undone. When I got a page that was "above my pay grade" (and many of them were), I would present the information to my residents but always come up with my own plan first. That said, plenty of pages were things like a simple question about the plan for a patient, and every one of these that I could handle on my own was one less thing my intern had to deal with. I would see consults and clinic patients and staff them with the junior resident or chief, giving my intern a chance to catch up on her work.

In case this comes across in the wrong way, let me say that I know an MS4 is not able to do everything that an intern does, and that allowing me to do certain things (like putting in orders that need to be cosigned) probably does add more work for my intern. My plans were not always the right ones, and of course there was information I forgot to consider and times I was way out in left field, but that's how you learn - it's a lower stress environment where you can practice making decisions without your decisions actually harming patients. If you want to be thought of as "on the level of an intern," act like one by taking full ownership of your patients and doing everything involved in their care, whether or not you consider it boring or scut work. Make an effort to learn how to do things right, like calling in consults or putting in NG tubes, so that you can be trusted to do these things correctly, and they become one less thing the rest of your team has to worry about. Do these things reliably and consistently and you will most likely find that you're trusted to do them more often, and with less and less supervision.

I think every medical student should be able to identify the problems their patients have, know what the plan is to address those problems, and be able to communicate intelligently with everyone from nurses to consultants about their patient. I've heard varying opinions on medical students calling in consults, but I think it's a skill that we should develop before intern year. The first time I did one as an MS3, my resident had me rehearse what I was going to say before I called anyone, and made sure I had the necessary chart information available before I called. By the end of the first week on that rotation, when we decided in the morning that one of my patients needed a consult, I would make sure that I knew exactly why we wanted it, and then call it in.

Edit: One more I forgot to mention - know the plans for every patient on your team, not just your own. Your intern is expected to keep track of every patient on the service, from lab values to consults, so if you want to act like an intern, you should do the same. If your intern is off seeing a consult and your chief comes out of the OR with a question about one of the patients you aren't covering, make an effort to know the answer. If you have downtime, check up on what new information is available on the rest of the team's patients. Go round on your own and see how everyone is doing, so you can be the one to report back "Mr. X in room 304 still hasn't made any urine, I think we should get a bladder scan and consider replacing his Foley." Better yet, "Mr. X in room 304 still hasn't made any urine, so I asked his nurse to get a bladder scan. Here is what she said. I'll go replace his Foley now if you think that would be appropriate."
 
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It simply means you worked really hard and were pleasant to have around. No medical student ever works at the level of a good intern. Interns work much harder and longer hours, and unlike students at our institution, they take call. Oops, interns don't do that either. <retract>
 
I think they throw that out there as a pretty nice complement. This student isnt totally stupid or lazy, ect.

Also as a fourth year esp we worked longer hours than interns, but less actual work of course. Med student hour restrictions weren't enforced, and you sure didn't complain about them if they were in a specialty you wanted to go into. Thirty hour call twice a week at one place.
 
SouthernSurgeon said:
That's very institutional dependent. Our med students' hours are veryprotected.
Click to expand...

Depends on the specialty. A MS3 is likely not going to be doing 30 hour call q2, but I know multiple friends interested in Neurosurgery or Orthopedics who did exactly that during their audition rotations as a MS4.
 
Interns work much harder and longer hours, and unlike students at our institution, they take call. Oops, interns don't do that either.
Click to expand...

Am I understanding you correctly? Interns don't take call at your institution? How does that work? Just your department, or all of them?
 
bc65 said:
Am I understanding you correctly? Interns don't take call at your institution? How does that work? Just your department, or all of them?
Click to expand...

At any institution. We are limited to 16 hours in hospital, so that precludes working during the day and taking overnight call.

Some programs rely on night float systems where there is an intern who comes on at like 6pm and leaves in the morning. This sucks for surgical interns because it means that you basically never get to the OR during night float.

Some general surgery programs are part of a randomized controlled trial to see whether intern work hour restrictions change outcomes, so the interns are eligible to work a maximum of 30 hours.

As a med student on a few rotations, I took q4-q6 overnight call. I probably worked more hours on those rotations than I do now as an intern, but I'm much more tired now since I'm much busier. Next year will be the pain train.
 
SouthernSurgeon said:
Generally speaking, for fourth year sub-I's the kid gloves come off, especially for away rotators. It's self motivation at that point though since they are focused on a very short term goal.

And it's still not as impressive as sub-I's seem to think they are. It's a lot easier to work your butt off when you know you're going to be chilling on a radiology elective (or on a beach in Thailand pretending it's a global health rotation, which seems to be a popular choice among our students based on their fb pics) in 4 weeks. Try working that hard for 5 years.

However, as one painful sub-I reminded my chief when I was a 2nd year, the school's duty hour policies still apply. Needless to say that was someone who was not going to be staying on in our residency...
Click to expand...

I don't completely disagree, but I think the sub-Is, at least in NSG and Ortho, took call more often than anyone else on the team. Discussing the rest of 4th year is kind of irrelevant to me, but I can see your point about 3 months vs 5 years (or maybe 4 years since interns can't take call) of routine call.

As to the bolded - that's a shame, IMO. Likely means the residency is not attributing to the 80 hour work week for its residents either. This seems so blatantly common across multiple surgical residencies. Sad that the residents feel compelled to lie about their work hours in order to not piss off their PD, rather than the practice hiring more PAs and the like to give the residents a break from 100+ hour work weeks.
 
DrShazam said:
- Write your own notes. A lot of med students think their notes are not valuable and it's a waste of time because nobody will see them. It's good practice, but you need to do it efficiently. Sign off on progress notes within an hour of rounding, and sign off on H&Ps within an hour of seeing a patient. Because interns don't have the luxury of time like med students do. In your note, always include discharge criteria and disposition- shows you know the clinical endpoints. We use EPIC here, and I always send my notes to the attending and chief- helps for feedback, shows the team you are actually trying to functional at the level of the intern. Plus, if you do it early enough, it can help the resident taking care of the patient.
- Always come up with your OWN plan. Super easy to just agree with the resident or harass him or her till they tell you what they're planing on doing, but part of being an intern is not relying on anyone else. Even if your plan is completely wrong (obviously it can't be absurd, but it doesn't have to be perfect), as long as you can defend it and show your thought process, nobody will fault you. This is one aspect I think students feel the most awkward about, but I try to put myself out there as much as I can now because it shows the attending you know what you're talking about, and can think on your own.
Click to expand...

First one:
Write your own notes? Not really. Your notes may be your own until the A&P. That's all dependent on the attending/resident. You're essentially filling out the other parts and inserting what the team agreed on. If you want a quick dismissal of your notes, then keep doing that.
Second one: That's the kind of mentality you learn can put you into the flames of hell with the team.
Being an intern is being the "secretary" for the team. You're making sure you have all the information discussed and putting it into the notes for the attending to sign off on.


Or wait... what specialty are we talking about?
 
Kaustikos said:
First one:
Write your own notes? Not really. Your notes may be your own until the A&P. That's all dependent on the attending/resident. You're essentially filling out the other parts and inserting what the team agreed on. If you want a quick dismissal of your notes, then keep doing that.
Second one: That's the kind of mentality you learn can put you into the flames of hell with the team.
Being an intern is being the "secretary" for the team. You're making sure you have all the information discussed and putting it into the notes for the attending to sign off on.


Or wait... what specialty are we talking about?
Click to expand...

Sorry you had a lousy experience, but it's not that way everywhere. The interns I've rotated with are expected to present a plan for their own patients and would be more likely to be ridiculed for standing back and acting like a mute secretary.

I've seen from your previous posts that you did an away at a pretty malignant place - so again, I'm sorry it sucked so hard, but I don't think it's fair to tell all future students and subIs that they should be silent. That's a great way to get a poor eval and lackluster LORs.
 
TraumaLlamaMD said:
Sorry you had a lousy experience, but it's not that way everywhere. The interns I've rotated with are expected to present a plan for their own patients and would be more likely to be ridiculed for standing back and acting like a mute secretary.

I've seen from your previous posts that you did an away at a pretty malignant place - so again, I'm sorry it sucked so hard, but I don't think it's fair to tell all future students and subIs that they should be silent. That's a great way to get a poor eval and lackluster LORs.
Click to expand...

I'm talking about being a medical student, not an intern necessarily.

Yes, that place wasn't the most enjoyable experience, but I've not seen interns necessarily dictate patient care to the level you describe. Everything else I agree with.
 
It really does depend on the rotation and the specialty.

On some rotations as a med student I would literally come up with plans by myself then just run it by the attending before putting in orders. On others I couldn't even write notes in the patient's chart.
 
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