Questions for IM Interns/Residents

[Redpancreas]

I've read lots of Intern Survival Guides (school specific one's, SDNs, NEJM's, and looking to order OME's before my SubI). They all seem to echo things like be punctual, work hard, stay humble, don't complain, know what you don't know, treat pt. not the numbers, etc. Outside of that, do you have any advice for Intern year for IM?

Basically, I haven't heard a lot on here about IM resident's role from actual residents and what it takes to be a good intern. Below is just a series of questions for IM interns mainly. Feel free to answer whichever ones interest you.

1. What time are you expected reach the floor/lounge? (if the answer depends on # of pts. how many do you typically work up and how many hours early/patient)

2. I've seen IM interns have roles similar to medical students where they'd get pimped on medical knowledge and are[ 85% R/15% I] on the RIME and I've seen others that are expected to manage their patients outside a few tweaks mainly based on attending preference.

3. I've never seen order sets but do you get in trouble for using them if something doesn't need to be ordered and you just clicked the order set?

4. Are you supposed to be the one admitting patients. Sometimes on rounds the IM/Peds/IM-Specialty the attending will interrupt my presentation and ask the residents why this patient's admitted (even if I gave the reason for consult/admission in my one-liner) and the residents are expected to respond.

5. One of my biggest weaknesses is critical care management (ACLS, Septic Shock, and pretty much all the pulmonary conditions like atelectasis, pneumothorax, effusions, and chest tubes, ventilation, oxygen, the endless asthma/copd devices etc.) How did you learn these skills?

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[Levo]

Not an IM intern, but will be one in a few weeks. My impression is that while the intern is the one to "carry" the patient on the floor, it is the resident on the team whose responsibility it is to decide whether a particular consult from the ED needs to be admitted to medicine or treated in the ED. At the program where I went to med school, it was common for the resident to quickly scope new ED consults and decide whether they're appropriate admissions, then if they decided "yes", the resident and intern would come back together to tag-team the H&P and admission orders. It would make sense then, that the resident would be the one to be asked "why is this patient admitted" because the resident was the one who made the call that the patient was an appropriate admission to medicine.

I wouldn't be worried about having weak ICU skills. At my home institution at least, there were more residents than interns in the ICU. Between that, the fellow who was always present, and a greater degree of attending supervision, the interns got plenty of support. If IM interns and residents were supposed to be good at ICU management, there wouldn't be a fellowship dedicated to it.

 

[togaedere]

Time pretty much answers a lot of these questions, but I will take a stab at some as well.

Time depends on how you work and what time you're rounding. So, on a day where we are rounding at 830 or so, I try to be at the hospital by 630. Gives me an hour or so to preround and an hour to see patients - these are the expectations of the intern, so it's pretty universal that you will be expected to know what happened overnight, what consultants said, what the result of key labs was, and what imaging was performed. Earlier in the year it took me longer to do all this stuff - but I've learned how to be slightly more efficient. I should say though that efficiency is still something I am working on. Basically, what time you need to be at the hospital depends on the demands of your program and how long you need to do the tasks required of you. Your job in intern year is to learn how to develop effective plans for patients.

Order sets are helpful for certain things and I believe hospital specific - but if there is a diagnosis that comes up a lot, or if there is a risk of missing key components then order sets can help to keep certain orders always in the forefront. Of course, if certain orders are not necessary then that aspect of the order set should not be clicked through.

I've read lots of Intern Survival Guides (school specific one's, SDNs, NEJM's, and looking to order OME's before my SubI). They all seem to echo things like be punctual, work hard, stay humble, don't complain, know what you don't know, treat pt. not the numbers, etc. Outside of that, do you have any advice for Intern year for IM?

Basically, I haven't heard a lot on here about IM resident's role from actual residents and what it takes to be a good intern. Below is just a series of questions for IM interns mainly. Feel free to answer whichever ones interest you.

Admissions I guess are hospital dependent but I will tell you what we do at mine (I'm a med peds intern at a program that has a lot of built in resident protection). On wards months, we are expected to take one admission per team per day. That means that on admission days (excluding our academic half days which are once per week and days in which we have clinic) one of two interns takes one admission. I haven't done a lot of admitting (this is a role for 2nd year residents at my hospital) aside from this, but during intern year (again, at my hospital, as this varies from place to place) it's the attending that accepts the admission request from the emergency department. Other people can speak to what it's like at other hospitals, but sometimes admissions can be pretty soft. People who came in for a mild complaint that has resolved by the time they made it to the floor, etc. Part of the mastery of residency is how to navigate negotiations with the emergency department to argue against admission requests when they are inappropriate. Possibly an attending who is asking a resident why a certain patient was admitted wants the resident to argue for the case, and to reveal sound thinking, and not just go along with an ED request just because someone asked.

For your last question, I think it's an important thing to realize that critical care is a fellowship, and internal medicine residents aren't really expected to be masters of management of critically ill patients. The answer is going to be time - MICU rotations, intercare services, spending a lot of time with patients on vents. This information will come. If you have questions regarding asthma/copd devices, I suggest making friends with a respiratory therapist and asking them to walk you through a lot of this stuff.

1. What time are you expected reach the floor/lounge? (if the answer depends on # of pts. how many do you typically work up and how many hours early/patient)

2. I've seen IM interns have roles similar to medical students where they'd get pimped on medical knowledge and are[ 85% R/15% I] on the RIME and I've seen others that are expected to manage their patients outside a few tweaks mainly based on attending preference.

3. I've never seen order sets but do you get in trouble for using them if something doesn't need to be ordered and you just clicked the order set?

4. Are you supposed to be the one admitting patients. Sometimes on rounds the IM/Peds/IM-Specialty the attending will interrupt my presentation and ask the residents why this patient's admitted (even if I gave the reason for consult/admission in my one-liner) and the residents are expected to respond.

5. One of my biggest weaknesses is critical care management (ACLS, Septic Shock, and pretty much all the pulmonary conditions like atelectasis, pneumothorax, effusions, and chest tubes, ventilation, oxygen, the endless asthma/copd devices etc.) How did you learn these skills?

 

[ActinicKeratosis]

I'm not an intern. I'm an M4. However from my experience on the medicine rotation is that intern responsibility is extremely variable. I found that some interns function relatively independently and others have the knowledge and skills of a second year medical student and need some serious supervision. It also seems to depend on the senior resident as well. Some are controlling and like to micromanage. Other seniors are more laid back and let others take more responsibility for their patients.

 

[WheezyBaby]

1. What time are you expected reach the floor/lounge? (if the answer depends on # of pts. how many do you typically work up and how many hours early/patient)

It all just depends, honestly. Number of patients, generally from 6-10 that are your primary responsibility, cross cover obviously significantly greater than that but you're not prerounding on them. How long you need to preround there's too much variable. First day of service, the patients can all be rocks and it's still going to take some time. ICU, generally going to take a little longer. In general, 30 minutes to a little over an hour to preround I'd guess, variable on number, complexity, familiarity, and how good I am at cutting off chattiness.

2. I've seen IM interns have roles similar to medical students where they'd get pimped on medical knowledge and are[ 85% R/15% I] on the RIME and I've seen others that are expected to manage their patients outside a few tweaks mainly based on attending preference.

Not sure exactly what the question is, but the statement's true. It's going to depend on the service and the staff. In general, my experience has been older staff and hospitalists are more hands off, younger staff and subspecialists are more hands on (at least with regard to their area of expertise).

3. I've never seen order sets but do you get in trouble for using them if something doesn't need to be ordered and you just clicked the order set?

You are absolutely responsible for any order you write.

4. Are you supposed to be the one admitting patients. Sometimes on rounds the IM/Peds/IM-Specialty the attending will interrupt my presentation and ask the residents why this patient's admitted (even if I gave the reason for consult/admission in my one-liner) and the residents are expected to respond.

As far as I'm aware, everywhere I've worked admits have to be accepted by staff. This may not be your staff who is on in the morning (e.g. nocturnist accepting for your team)

5. One of my biggest weaknesses is critical care management (ACLS, Septic Shock, and pretty much all the pulmonary conditions like atelectasis, pneumothorax, effusions, and chest tubes, ventilation, oxygen, the endless asthma/copd devices etc.) How did you learn these skills?

Reading and exposure. No magic tricks here

 

[CherryRedDracul]

About to finish up my intern year in IM.

1. What time are you expected reach the floor/lounge? (if the answer depends on # of pts. how many do you typically work up and how many hours early/patient)

At the latest, 7 AM so I can relieve the covering night team of their duties. If I have a complicated list, maybe 6:30 AM. At the max, I have 10 patients, but many times I'd be down to 2-3 after working hard discharging patients who were stabilized and could be followed up outpatient. We'd typically round around 9-9:30 AM so I'd have 2-2.5 hours to see all my patients, write the notes, and manage them. Since we still have handwritten progress notes at my institution, I have to make sure I have enough time writing them all out; I also need to make sure I have extra time to respond to urgent or emergent matters with my patients. If I'm on call, I also need to make time for new admissions or holdovers from the night before.

2. I've seen IM interns have roles similar to medical students where they'd get pimped on medical knowledge and are[ 85% R/15% I] on the RIME and I've seen others that are expected to manage their patients outside a few tweaks mainly based on attending preference.

Early during intern year, attendings will expect you to be an advanced medical student for the most part. After several months of getting a hang of the ropes, I was expected to make most of the management decisions. By November, I was managing patients on my own for the most part, getting input from the attending for less clear-cut problems.

3. I've never seen order sets but do you get in trouble for using them if something doesn't need to be ordered and you just clicked the order set?

IMO, it's bad practice shotgunning orders without having a question in mind. Every order I put in has a purpose behind it, whether it is active management or I am trying to ask a question. If I'm ordering a CBC for the next morning, I always ask myself,"Do I expect the results from this CBC to likely change management in any way. By getting this CBC, will I be treating the patient or just my own anxieties?". By shotgunning order sets, you're increasing costs for no clear benefit. I'm a minimalist at heart, so I'm the type of intern who can have several patients on my list with no AM labs needed.

Now, would you get in trouble? Depends on the attending. Is the attending a minimalist? Then possibly. Is the attending fond of pan-consulting? You'd probably be encouraged to order everything under the sun.

Are you supposed to be the one admitting patients. Sometimes on rounds the IM/Peds/IM-Specialty the attending will interrupt my presentation and ask the residents why this patient's admitted (even if I gave the reason for consult/admission in my one-liner) and the residents are expected to respond.

At least at my institution, it is the intern's responsibility to admit the patient. By that, I mean complete the evaluation and the H&P for the patient. As far as I know, at most places, the ED makes the decision to admit a patient to a service and then contacts that service's attending to complete the admission. If that service's attending decides to argue against that admission, then it becomes his responsibility to discharge the patient his/herself. Otherwise, the onus falls on you. Many times, you will get ultimately BS admissions and it won't be your fault. You'll just have a quicker discharge.

5. One of my biggest weaknesses is critical care management (ACLS, Septic Shock, and pretty much all the pulmonary conditions like atelectasis, pneumothorax, effusions, and chest tubes, ventilation, oxygen, the endless asthma/copd devices etc.) How did you learn these skills?

Lots of reading, watching videos, learning from other residents/fellows/attendings. As far as procedural skills, you learn them by observing them and, most importantly, doing them.

There's no real shortcut to improving your fund of knowledge. Just gotta keep reading, watching, and doing. If you want a good book on the basics of ICU management, check out Marino's The ICU Book. If you like podcasts and whatever's going on at the cutting edge of critical care, check out EMCrit Blog - Emergency Department Critical Care & Resuscitation and it's nested section PulmCrit.

 

[cbrons]

I've read lots of Intern Survival Guides (school specific one's, SDNs, NEJM's, and looking to order OME's before my SubI).

There are a few books out there touting themselves as "Intern survival guides" with scenarios of what to do in what situations. Sadly, the three or four that I've looked at are woefully out-of-date with terrible information. Other times, they have broad overviews of problems and differentials with little info on what to actually do, specific tests to order, etc.

 

[cbrons]

I think the best resources for what to do in what situations comes from reading/watching podcasts or lectures. I absolutely love some of the stuff they've put out there in the FOAM world. Louisville lectures, Curbsiders podcast, EMCrit, Intensive Care Network podcast, Persiflager's infectious disease podcast, etc.
I am also quite favorable to reading the big boy textbooks, like big Cecil and Harrison's. This is also a great resource for hospital medicine in particular:
Principles and Practice of Hospital Medicine, 2e

(If your residency program or medical school has access to AccessMedicine, this book is free).

 

[Domperidone]

There's more day-to-day sorta details in the following post on SDN: Help me turn things around. If that's also what you're after

Edit: oops, forgot to add, in addition to the other responses in here. (which is a strong collection you're getting)

 

[Snoopy2006]

I've read lots of Intern Survival Guides (school specific one's, SDNs, NEJM's, and looking to order OME's before my SubI). They all seem to echo things like be punctual, work hard, stay humble, don't complain, know what you don't know, treat pt. not the numbers, etc. Outside of that, do you have any advice for Intern year for IM?

Basically, I haven't heard a lot on here about IM resident's role from actual residents and what it takes to be a good intern. Below is just a series of questions for IM interns mainly. Feel free to answer whichever ones interest you.

1. What time are you expected reach the floor/lounge? (if the answer depends on # of pts. how many do you typically work up and how many hours early/patient)

2. I've seen IM interns have roles similar to medical students where they'd get pimped on medical knowledge and are[ 85% R/15% I] on the RIME and I've seen others that are expected to manage their patients outside a few tweaks mainly based on attending preference.

3. I've never seen order sets but do you get in trouble for using them if something doesn't need to be ordered and you just clicked the order set?

4. Are you supposed to be the one admitting patients. Sometimes on rounds the IM/Peds/IM-Specialty the attending will interrupt my presentation and ask the residents why this patient's admitted (even if I gave the reason for consult/admission in my one-liner) and the residents are expected to respond.

5. One of my biggest weaknesses is critical care management (ACLS, Septic Shock, and pretty much all the pulmonary conditions like atelectasis, pneumothorax, effusions, and chest tubes, ventilation, oxygen, the endless asthma/copd devices etc.) How did you learn these skills?

1. Others have given you a good idea of what typical IM programs were like. Mine was a little more atypical. There was a mandatory morning report at 7 and rounds started immediately after, so as a beginning intern carrying 10 patients I was in the hospital at 5 AM when I was coming on service and trying to learn patients. The number got later as I became more familiar with the team and more efficient. In most programs (like at my medical school) interns show up between 6:30 and 7 to preround.

2. I also don't understand this question. If you're asking how involved/intense your attendings will be, it completely varies. I had some attendings that were very Socratic in their teaching methods - lots of pimping, rounds lasted all day. Others were efficient and only asked questions if it would make a difference clinically to the patient.

3. You use order sets to admit, but they're customizable. Each time you open an order set, you'll go through and check each line to see what was pre-selected. Of course you're responsible if you weren't thorough enough while looking through the order set and checked off the wrong item.

4. Generally admissions are given to the interns. Usually (depending on your team) you'll quickly staff the case with your senior and run through your plan before presenting to an attending. But yeah, being a resident is different than being a medical student. You're the doctor now. You call the shots, with guidance.

5. If your medical school has a simulation lab, take full advantage while you're in medical school. Also go to every code you can as a medical student and ask questions. Be on the lookout for procedures (e.g. if my surgical team was busy writing notes and there was an art line being placed somewhere else in the SICU, I'd ask the other residents if I could watch if they didn't already have a med student with them. Usually got extra procedures this way).

If you're out of med school, then the best you can do is learn on the job. Read through the guidelines. During downtime, run through the guidelines with seniors and have them present mock rapid response scenarios. If you're not comfortable running a code at the beginning of residency, then go to as many as you can and stand alongside your senior and follow their thought process. How much responsibility interns carry during code situations vary from program to program and from individual to individual.

 

[masaraksh]

This thread is very uplifting because I am hoping to set the bar very low for myself during intern year and basically push the boundaries of how little work I can get away with. 🙂

I plan to come in at 9, check some CBCs, put in antibiotic orders and go missing for the afternoon.