Starting a GS Residency

[Imhetep]

First of all, I'd just like to thank everyone for their posts. I've been reading here since before med school, and now that I've matched I figured it was time to join.

As the soon to be lowest employed life form in the hospital, and after sobering up after the weekend, I've had the opportunity to reflect on the past few years. I realize that there are tons of little bits of wisdom that I've collected about medical school that fit into a category that neither clinical nor scientific but nonetheless, I wish I knew before I figured them out. You know - I should have talked to my school's surgery chair before third year, research is always a good thing, the surgery shelf is more medicine than surgery, etc. In the spirit of not repeating the same style of mistakes over and over and over again, I figured I would turn to a group of trusted experts. So is there anything that you wish you learned/was told/figured out before you did in your surgical residency?

Thanks.

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[Winged Scapula]

- ordering a test is not the same as it being done
- a fresh pair of socks and underwear make all the difference post call
- you will gain weight if you do not make time for exercise
- read, read, read...even if its only 10 minutes a night
- 5 years goes by really quickly
- wear TEDs; your spidery veined legs will not be pretty 7 years later
- I don't know is not an acceptable answer
- if you really don't know, at least know how you can find the answer out
- complain on the inside; someone will always have it harder than you
- make friends with the anesthesia and rads residents; you will spend a lot
of time with them
- trust no one; look things up yourself
- a pocket handbook is faster than a PDA
- knowing how to do a procedure is often not the most important part
- learn as much as you can about things like billing, coding, etc. as you can while a resident
- no one will teach you about how to find a job after residency; start trying to learn early

 

[Pollicis]

Great advice. Seriously. Thanks for this. I wonder if people can continue to post their little bits of wisdom.

As for the pocket handbook being faster than a PDA...I'll take you on. I'm pretty handy with my PDA

 

[SocialistMD]

No matter how busy your night, there is always time to call your s.o. and tell them good night. If you want them to stay with you, you should probably do it.

 

[SLUser11]

First of all, I'd just like to thank everyone for their posts. I've been reading here since before med school, and now that I've matched I figured it was time to join.

As the soon to be lowest employed life form in the hospital, and after sobering up after the weekend, I've had the opportunity to reflect on the past few years. I realize that there are tons of little bits of wisdom that I've collected about medical school that fit into a category that neither clinical nor scientific but nonetheless, I wish I knew before I figured them out. You know - I should have talked to my school's surgery chair before third year, research is always a good thing, the surgery shelf is more medicine than surgery, etc. In the spirit of not repeating the same style of mistakes over and over and over again, I figured I would turn to a group of trusted experts. So is there anything that you wish you learned/was told/figured out before you did in your surgical residency?

Thanks.

My advice to the interns is to do your discharge summaries as you are discharging the patient. Otherwise, they build up big time.

Also, it's like a fork on a chalkboard every time I hear that "the surgery shelf is mostly medicine." There are no questions regarding the number of knots for vicryl or some other technical detail, so I guess to the "questionable admit" there's no surgery on there, but I certainly don't remember questions on essential HTN, community acquired pneumonia, otitis, etc. The test is mostly surgical disease, perioperative care, etc.

Try reading just MKSAP or First Aid for Medicine and then see how you do on the shelf.



ps I also agree that calling your wife is a good idea.....

 

[SLUser11]

Also, it's like a fork on a chalkboard every time I hear that "the surgery shelf is mostly medicine." There are no questions regarding the number of knots for vicryl or some other technical detail, so I guess to the "questionable admit" there's no surgery on there, but I certainly don't remember questions on essential HTN, community acquired pneumonia, otitis, etc. The test is mostly surgical disease, perioperative care, etc.

Quoting myself here.....

Here's a great thread that illustrates my point.

post #6 quoted below:

I couldn't disagree more.........I think most people on this board when you look at threads historically agree that the surgery shelf is a disguised medicine exam.

Lots of fluids, electrolytes, nutrition, mostly diagnosing common medical problems like choleycystitis, appendicitis, cardiac tamponade all things covered in medicine. Gi bleeding (again medicine) etc....

hardly any surgery.

study medicine and trauma and you'll be fine.

later

What? "Common medical problems" like cholecystitis, appendicitis, GI bleeds, cardiac tamponade...."hardly any surgery..." OH MY GOD ARE YOU KIDDING ME?!? That's medicine? What is surgery then?


What exactly do med students think we do?



Anyway, the same poster goes on to make about five more really ignorant comments, and justifies his points with "well, everyone on SDN says it's all medicine, so it must be." But, that thread is like 3 years old.....sorry, just wanted to illustrate my point.

 

[Blade28]

Yeah, by "it's mostly medicine," what the med students mean is there are no questions about surgical technique, and very few questions on anatomy.

 

[SocialistMD]

The FP shelf is mostly medicine, too.

 

[MediCane2006]

This forum has a few similar threads with a lot of good advice....I'm sure I'll just be repeating what others have said, but here goes.

1. The dullest pencil is sharper than the smartest intern, i.e., write EVERYTHING down in an organized way. At our hospital we have a signout list with blank spaces next to each patient name that makes writing down to-do lists, lab results, etc easy, but find a way that works with your hospital's system. Don't count on your memory. I used to make an organized to-do list broken down by task-type (phone calls, floor tasks, post-ops,etc) while we were running the list in the morning, make a list of stuff to tell the chief when I went in to the OR, etc.

2. The patient is the one with the disease - cheesy line from House of God, but remember to take the time to take care of yourself. Figure out when you can squeeze in a workout a couple times a week. Plan healthy meals - eating too many drug rep lunches and greasy cafeteria food will lead to waking up one morning and realizing your scrubs don't fit, and it's a lot harder to lose the weight on an intern schedule rather than keep from gaining it in the first place (definitely something I wish someone would have told me!). Go to bed early enough to get six hours of sleep during the week (most days). Make time to talk to your family/SO/pet/whatever daily. Go out and grab a beer after work on Friday nights. You get the idea.

3. Be nice - to attendings, ancillary staff, fellow residents, etc. It's hard, because the hospital is a very stressful place and tempers often run short. But people really do look out for each other, and having a strong support system within the hospital really helps. I can't tell you what a difference it makes to have a solid relationship with the OR nurses, scrub techs, unit clerks, etc...while it may seem unimportant, when you're covering a busy service it's nice to have them looking out for you rather than looking for ways to make your day more miserable

4. Listen to the nurses. No, they didn't go to medical school. Yes, there are some lazy/annoying/just plain bad nurses out there. No, you shouldn't do something just because the nurse tells you it's the right thing to do. But remember that nurses have a very different view of a patient than you do. You see that patient for ten minutes (maybe) on rounds, once or twice more during the day. The nurse sees that patient day in and day out. So when a nurse approaches you with a concern, LISTEN with an open mind.

5. Don't be a lazy intern. Keep an eye on details - ins/outs, dvt prophylaxis, iv fluid rates, etc. Always re-assess your patients in the afternoon before evening rounds. Always check things if you're not sure about them. Follow up on tests that you ordered - sure the order for that ultrasound is in, but calling the tech and explaining why you need it done stat will ensure that it does indeed get done. Keep track of consultant recommendations (it's good to chart-check these on your afternoon mini-rounds when you're checking in on your patients). One of the things that makes a great intern is that willingness to go the extra mile - running the sample down to the lab, wheeling the patient to x-ray yourself, going down to talk to the radiologist when the film hasn't been read yet. With all of this running around, I also recommend a comfortable pair of shoes

6. Finally, there is a plaque in our surgery call room that contains the five rules for surgical residency as set down by one of our current residents. Here they are:
1. Never trust anyone
2. Never trust a patient
3. Never expect to be respected
4. You can be dumb and nice, and people will like you. You can be smart and an a$$hole, and people will respect you. But no one likes or respects a dumb a$$hole.
5. You can't change a dumb a$$hole, you just have to figure out a way to work around them.

 

[smq123]

.

 

[Castro Viejo]

Stay away from the cafeteria sushi (and other exotics) during your months on Trauma, Vascular, CVTS, or SICU.

 

[Winged Scapula]

- always have a bag available with essentials, even if you aren't on call: this would include medications you may need (although you can often talk the SICU into giving you something for nausea or a migraine, its better to bring it from home), healthy snacks, change of socks and underwear (for those cases that are a little juicy)

- for females: do not rely on your memory or ability to take the OCP regularly and at the same time. Use the Nuva Ring, a patch, have your partner get his vas clipped, stay abstinent or get your own tubes tied. Many a female resident has found themselves scared or actually pregnant because they messed up their OCPs

- get loupes early if your program requires them; if they do not and you have to pay for them, get a group together to have the reps come and show you whats available and for what price. My program would not let us scrub on Peds cases until we had loupes; fortunately, they paid for them. Some do not.

- get online bill pay

- call consults early; just as we hate the "Friday night dump", its also unfair to call medicine at 5:00 pm. Just be aware that if you call before 8 am, they may tell you to call back for the "day shift" resident.

- see what the culture is at your program; some expect that interns only tie two handed knots, even if you were doing one handed ties as a 4th year Sub-I

- socialize with your colleagues; things work a lot better if residents are friendly, and you'll find it a lot easier when you need a favor if you've been known to do them for others

- write legibly

- answer your pages and in a timely fashion

- if you don't know the dosage, route, etc. of something, ask...don't leave it blank

 

[TXSurgResident]

1 "That's a cross-cover patient" is the statement of a fact which 99% of the time doesn't answer the question asked. It will also not help you at M+M. Therefore demand (and provide) detailed signouts.

2 Never talk smack about anyone when ancillary staff or medical students are around. Take it to the bar.

3 ER residents, IM, FP, Pediatrons, OB etc. may be where you get your referrals in a few years. Your reputation, good or bad, may precede you. If they are intolerable/kill someone/really cute, see #2.

4 Never boldly place a chest tube where your finger has not gone before. This avoids the xray you never want to see

5 "Keep fit and have fun!" -Hal and Joanne

 

[TXSurgResident]

Dr. C, shouldn't the attendings be in bed by now??

My bad... Sunny AZ time zone...

 

[Winged Scapula]

Dr. C, shouldn't the attendings be in bed by now??

My bad... Sunny AZ time zone...

I'm not much of a sleeper...if I went to bed this early, I'd be up by 1:30 PST. I'll turn out the lights in about 3 hrs or so.

 

[njbmd]

- always have a bag available with essentials, even if you aren't on call: this would include medications you may need (although you can often talk the SICU into giving you something for nausea or a migraine, its better to bring it from home), healthy snacks, change of socks and underwear (for those cases that are a little juicy)

- for females: do not rely on your memory or ability to take the OCP regularly and at the same time. Use the Nuva Ring, a patch, have your partner get his vas clipped, stay abstinent or get your own tubes tied. Many a female resident has found themselves scared or actually pregnant because they messed up their OCPs

- get loupes early if your program requires them; if they do not and you have to pay for them, get a group together to have the reps come and show you whats available and for what price. My program would not let us scrub on Peds cases until we had loupes; fortunately, they paid for them. Some do not.

- get online bill pay

- call consults early; just as we hate the "Friday night dump", its also unfair to call medicine at 5:00 pm. Just be aware that if you call before 8 am, they may tell you to call back for the "day shift" resident.

- see what the culture is at your program; some expect that interns only tie two handed knots, even if you were doing one handed ties as a 4th year Sub-I

- socialize with your colleagues; things work a lot better if residents are friendly, and you'll find it a lot easier when you need a favor if you've been known to do them for others

- write legibly

- answer your pages and in a timely fashion

- if you don't know the dosage, route, etc. of something, ask...don't leave it blank

Adding to that on call bag: anti-itch cream. I found myself in call rooms with "roomates of the arthropod kind" more than once. I always kept several changes of underwear, toothbrush, my favorite toothpaste (hospital-kind was always nasty), my shower gel, my shampoo etc. I kept Clorox wipes in my locker for those call room bathrooms that were less than spiffy too.

I also kept a thick sweatshirt in my call bag and another in my locker. I was always freezing in the hospital (winter and summer). I wore thick wool socks, a thick sweatshirt and slept under the ICU "French fry" lights on most call nights. I have a set in my office now. I never warn up unless I was doing peds surgery or cases longer than 3 hours.

Definitely make sure your Birth control is working. I was a DepoProvera person myself. I would never have trusted myself to remember to take OCP with a call schedule.

I second the TED hose. They were lifesavers for me. I also spent some quality time choosing my OR footwear (nothing with laces) carefully too.

Loupes were required by my program and they furnished 2.5X. If you wanted anything else, purchase during residency because the cost doubles when you become an attending. My program also purchased headlights for us too.

I learned to answer the phone with a smile in my voice. You never know who is on the other end (could be your attending) and you want to sound fresh and ready for action. It's hard at 4:45AM and you just laid down but cultivate good will, good manners and politeness toward everyone, especially those who wake you up in the middle of the night.

Go see the patient. Unless you know exactly what the problem entails, get out of the rack and see the patient if something starts brewing in the middle of the night.

I gave up my PDA for a pocket book. I ended up dropping too many PDAs and cracking screens. I kept my PDA for boredom but used pocketbooks for most routine things. I went through 3 PDAs in my first six months of residency. I seem to always manage to keep my little pocket books for the entire year.

Drink plenty of water. Coffee, Mountain Dew and colas are all dehydrating. Dehydration makes you tired and cranky. I kept a Brita pitcher around so that I would have good-tasting water. All of our floors had soft drink fountains for cola, ginger ale, iced tea but I just drank mostly water except on AM rounds (had to have good coffee).

If you are sick, stay home. I am talking about being really sick (not the sniffles). If you have a significant fever >38.5C, then stay home and don't infect the whole service. I came to work one time with 39.9C, tried to keep myself hydrated and warm to no avail. I was miserable for 3 days when one day of rest probably would have been a better course of action. I tried not to infect anyone but I was washed out and likely ineffective. My chief finally sent me home after 3 days. If you are sick, stay home, rest and recover.

Respect your fellow residents and never say anything about anyone that you wouldn't want said about you. Don't gossip and don't put your personal business out in the hospital. Be cordial and a good colleague but keep your personal and professional life separate.

No matter how large the hospital, gossip will happen. Just don't be the source of it. I always remember one of my colleagues who was accused of spreading Gardeneralla through the nursing staff in the SICU. This is not a good situation. Don't mix business with pleasure.

Ditto on avoiding the cafeteria "exotic specials". Sometimes things just won't agree with you and having a case of the "Aztec two-step" is just misery. In the OR, misery become "misery with bright lights".

I read at least 30 minutes per day and a couple of hours on weekends. I made myself read post call. After a couple of weeks, it became a good habit. I also made myself walk the stairs and brisk walk when I was feeling tired and run-down. There is nothing like aerobic exercise to calm your stress and keep you feeling more energetic.

A soak in the hot tub can make most things go far away. This is equally true of a good pedicure. Take care of your feet and back.

 

[Castro Viejo]

The nurses really don't think you're that good looking.

 

[Winged Scapula]

The nurses really don't think you're that good looking.

NB: the nurses/techs/students aren't flirting with you because of your sparkling personality, hot body or handsome face but rather because they are looking to bag a rich doctor and stop working.

There's a reason why you don't see very many young pretty nurses working outside of the peds floors.

 

[DoctorMunchkin]

A few more thoughts

- dont do anything you would be embarassed to tell your mother about. This holds pretty true for life. If you chew out a nurse or act like and a$$ - what would your mother say?

- be nice to the nurses. They can save you or throw you under the bus. It only takes one time of being a jerk to piss off the entire floor.

- dont blame your mistakes at work on things at home. You should be able to handle it all.

- For females - get the IUD. It lasts for five years, no shots, no kids, no having to remember ANYTHING. I can barely remember how to get to work some days, let alone when to take a stupid little pill. (Wish I would have figured the IUD thing out earlier - there might not have been an addition to my family at the beginning of my second year!)

- find a good friend for listening. We all need one every now and then. Someon who will let you vent and not make judgement calls.

- Dont forget your family - they have been there through a lot - take some time to tell them you love them - this include your parents.

- and last but not least - your attendings are NOT your friends. Some may be eventually, but until you are done, consider them teachers and nothing else. Watch your p's and q's and keep it professional.

 

[SLUser11]

There's a reason why you don't see very many young pretty nurses working outside of the peds floors.

I do.....every day.

I guess that's one of the advantages of working in a community hospital.

That was one of the quickest lessons I learned in med school when I left SLU Hospital and did a rotation at a community hospital in the St. Louis suburbs:
1. Nurses are hotter
2. Nurses are nicer
3. Nurses are less bitter

This leads to nicer, prettier people who are more eager to help you, and treat you with respect. I couldn't believe it at first, but it's held true for the last 3 years.

Of course, there are still plenty of ugly ones....but they're overall much nicer, also. The circle of antagonism isn't as engrained into the community system.

 

[Winged Scapula]

My comment was meant a bit tongue in cheek because we obviously have some attractive nurses and techs outside of the peds floor, but you may have a point...they may very well be nicer and prettier in community hospitals.

(but they still aren't flirting with you because you're hot)

NB: the IUD is a good choice for parous residents but in the nulliparous they tend to have higher rates of expulsion, pain with insertion and generalized discomfort. YMMV.

 

[Castro Viejo]

The walls in the call room "suites" are very thin.

 

[Winged Scapula]

The walls in the call room "suites" are very thin.

EXCELLENT point.

I'll put up with hearing your pager go off when I"m trying to sleep, but please. I don't want to hear your latest fight with your spouse, you having sex with (insert partner of choice here), your tv blaring, etc. If you don't care to share the information/noises with everyone be a little more discrete because otherwise we'll all know your bizness.

 

[surgiwho]

Shower! I know sometimes it's difficult because of the lack of time but a shower for me is a life saver in the am during call. It just seems to make the rest of the day so much better.

 

[njbmd]

The nurses really don't think you're that good looking.

Only Dr. CV is "that" good looking. If you are not Castro Viejo, you are not that good looking. That's why I am running for president of his fan club next year.

NB: the IUD is a good choice for parous residents but in the nulliparous they tend to have higher rates of expulsion, pain with insertion and generalized discomfort. YMMV.

Not to mention that the partner kept "bumping into" that little string. Ouch! I got rid of this within one month of having it put in. Bad juju!

The walls in the call room "suites" are very thin.

Dr. CV speaks from experience here. Don't do anything in the call room except "call-related" activities which should not make noise that travels through the walls. You don't want to be known at "room serviced". Don't even snore in the call room.

Yes, please, please shower and brush your teeth post-call. Use deodorant too but skip the smelly aftershave. Change the scrubs and change the lab coat before it gets filthy around the collar. I have found myself writing more than one "basic hygiene" note to the new male intern. Females haven't been bad on this one.

 

[Dr. V]

I have a couple of little tidbits to add.

Never, ever lie about anything. If you didn't see the lab/test/film/patient admit it and go from there. It's extremely poor form to claim a rectal exam was normal when they end up having a large, palpable rectal mass. It happens and people get caught. If you lie you have just lost all trust the rest of the residents and attending will have in you, and you may NEVER get it back.

Now in these days of 80 hours and fragmented services this one comes up from time to time.

2. When an attending tells you to do something or take care of something the correct answer is NOT "he's not my patient" nor any variation thereof such as "Joe will do that it's his patient". The attending DOES NOT CARE. All he wants is to make sure it's done. So the correct response is YES SIR/MAM, IT WILL BE TAKEN CARE OF. Then, if it's not your patient and not something you need to do YOU go find the correct resident and convey the attendings wishes to them and help if you can. If it is your patient then go take care of it but by all means MAKE SURE IT GETS DONE. "It's not my patient" isn't an excuse. Sure if it's not done the attending will figgure out that Joe was taking care of the patient, but he didn't tell Joe to do it he told YOU and bottom line is it will be YOU he's pissed at.

The other thing is that he/she WILL notice that you handled the situation even if it wasn't your patient. They will figgure it out eventually that it wasn't your patient and they will know they can depend on you to help take care of the patients regardless. That translates into more autonomy and more trust all the way around. (I would not advise doing things on other peoples patients, I am only advising that you find the CORRECT person so that it gets done and help if you can/if they need it).

 

[Castro Viejo]

EXCELLENT point.

I'll put up with hearing your pager go off when I"m trying to sleep, but please. I don't want to hear your latest fight with your spouse, you having sex with (insert partner of choice here), your tv blaring, etc. If you don't care to share the information/noises with everyone be a little more discrete because otherwise we'll all know your bizness.

I just love the people who fail to realize just how cheaply made those walls are that separate the call rooms in the suite. They provide for much entertainment. But of course now in my Chief year they've banished me out of the call room suite, to an office suite with a bunch of stuffy Radiologists, who just aren't as much fun and kinda nerdy.

I mean, who the hell cares that you're "killing Warcraft" on the weekends instead of having a normal sex life?

 

[Castro Viejo]

Only Dr. CV is "that" good looking. If you are not Castro Viejo, you are not that good looking. That's why I am running for president of his fan club next year.

Did you decide to take that job? Pretty please? I need to know someone there next year.

Not to mention that the partner kept "bumping into" that little string.

That'll leave a mark.

Dr. CV speaks from experience here. Don't do anything in the call room except "call-related" activities which should not make noise that travels through the walls. You don't want to be known at "room serviced". Don't even snore in the call room.

Yeah, really. I once had a burrito for lunch from the cafeteria (sort of "exotic" for a hospital -- reference above, please) and got kinda gassy from the beans. Needless to say the Peds and Medicine residents were chuckling at my need to, uh, flatulate every hour.

It did make for an interesting month on General Surgery though! It's fun to see your Chief Resident panic while he's doing a AAA repair or something and then,

<sniff> <sniff>

Chief: "Hey, what the . . . ?"

Attending: "What? What the hell? Did you nick the bowel?"

Chief: (panicking while running the bowel and stammering...) "Uh, uh, I don't think I did... F**k, Goddamn it!"

Attending: "I'll fire your stupid *** if that's what you did."

 

[Castro Viejo]

If you're a heavy sleeper (i.e., a pager doesn't wake you up), sleep with the lights on in the room and flat on your back. Don't get too comfortable.

 

[Winged Scapula]

If you're a heavy sleeper (i.e., a pager doesn't wake you up), sleep with the lights on in the room and flat on your back. Don't get too comfortable.

Having had more than one intern who used to sleep through his pages (I actually witnessed it as Vascular Chief when I had to come in from home to check on a patient because OSA intern wasn't answering...I was not happy)...I recommended pinning it to the top of your scrubs. Seemed to work with my OSA guys.

 

[smq123]

I recommended pinning it to the top of your scrubs. Seemed to work with my OSA guys.

It does - when it's on vibrate and clipped to your scrub top, it's like a sternal rub.

 

[tacobell]

On rounds, check the tubes (Foley, drains, etc.) - don't just look at how much came out on the flow sheet - there's a hella difference between blood and bile coming out from the intra-peritoneal and the intra-biliary drains (along similar lines, label your drains post-op - I once saw someone fed tube feeds through their CHOLCYSTOSTOMY tube - that CAN'T be good)

When you examine someone, make sure you do so with with their body exposed. That way, you don't miss the surgical scar / incisional hernia / fungating breast mass that the attending then notices on rounds. Sounds basic but it's something that I've seen forgotten way too many times.

NEVER, EVER drive home if you're too sleepy post-call. Sleep in the call room for 15 minutes or so. We lost a resident in my program when she drove home too tired post call and I'm sure many of the people here can tell you a story or eight about falling asleep behind the wheel.

 

[dynx]

2. When an attending tells you to do something or take care of something the correct answer is NOT "he's not my patient" nor any variation thereof such as "Joe will do that it's his patient". The attending DOES NOT CARE. All he wants is to make sure it's done. So the correct response is YES SIR/MAM, IT WILL BE TAKEN CARE OF. Then, if it's not your patient and not something you need to do YOU go find the correct resident and convey the attendings wishes to them and help if you can. If it is your patient then go take care of it but by all means MAKE SURE IT GETS DONE. "It's not my patient" isn't an excuse. Sure if it's not done the attending will figgure out that Joe was taking care of the patient, but he didn't tell Joe to do it he told YOU and bottom line is it will be YOU he's pissed at.

This way the attending does the least amount of work possible and never has to actually figure out how the teams are organized...which is important because, ummm, well...they, ummm wait, I know this.

The other thing is that he/she WILL notice that you handled the situation even if it wasn't your patient. They will figgure it out eventually that it wasn't your patient and they will know they can depend on you to help take care of the patients regardless. That translates into more autonomy and more trust all the way around. (I would not advise doing things on other peoples patients, I am only advising that you find the CORRECT person so that it gets done and help if you can/if they need it).

At this point they will realize instead of taking the time to figure out who to ask like a normal person would they can continue to dump **** on you and you'll run around like a monkey and make it happen. This contributes to your education by...damn, wait...this is a hard one too.

We don't take this from nurses who call us repeatedly about patients that aren't ours, and if we do we get hammer paged with every little thing since we're the "only resident that calls back". However, as brow-beaten little sheep we're supposed to take it from attendings?
How about finding a pair?

 

[DoctorMunchkin]

Having had more than one intern who used to sleep through his pages (I actually witnessed it as Vascular Chief when I had to come in from home to check on a patient because OSA intern wasn't answering...I was not happy)...I recommended pinning it to the top of your scrubs. Seemed to work with my OSA guys.

I had a previous chief that would put it on vibrate and tape it to his forehead!!

The other thing he would do is put it in a bowl of change!

 

[Dr. V]

However, as brow-beaten little sheep we're supposed to take it from attendings?
How about finding a pair?

No need to "find" a pair, had them all my life.

It's not "brow beaten sheep" THE ATTENDINGS ARE OUR BOSSES. I don't know why the chain of command is so hard to understand for some people.

No different than when a Chief asks you to do something. You don't make excuses, you say "Yes Sir/Mam" .

I know people with this attitude think it's "ballsy", but really it's just childish/lazy.

In my experience those with that attitude and the "how is that educational, waaa" attitude have never actually had to work for anything in their life and have no concept of earning anything or putting your time in. It's no different in real life, in the military or the factory. The boss is the boss.

Yes Sir/Mam will take you a long way in residency. Just remember that because the attendings/chiefs have earned the right for you to say that.

It may not be that way everywhere, but at least here the attendings/chiefs never ask us to do things that they wouldn't do/haven't done and we are not their scut monkeys. If it is different where you are at I am truly sorry for that.

 

[Castro Viejo]

No need to "find" a pair, had them all my life.

It's not "brow beaten sheep" THE ATTENDINGS ARE OUR BOSSES. I don't know why the chain of command is so hard to understand for some people.

No different than when a Chief asks you to do something. You don't make excuses, you say "Yes Sir/Mam" .

I know people with this attitude think it's "ballsy", but really it's just childish/lazy.

In my experience those with that attitude and the "how is that educational, waaa" attitude have never actually had to work for anything in their life and have no concept of earning anything or putting your time in. It's no different in real life, in the military or the factory. The boss is the boss.

Yes Sir/Mam will take you a long way in residency. Just remember that because the attendings/chiefs have earned the right for you to say that.

It may not be that way everywhere, but at least here the attendings/chiefs never ask us to do things that they wouldn't do/haven't done and we are not their scut monkeys. If it is different where you are at I am truly sorry for that.

Word up.

 

[Winged Scapula]

Double word up.

Perhaps because I was raised in a military family it was easier for me to automatically call my attendings and Chief residents Sir or Ma'm and to do whatever they asked of me.

I see this as no different than if I worked at Safeway and the manager asked me to stay late to help stock the oatmeal. They are our bosses, and most of the time aren't asking for anything they wouldn't do themselves.

It is true that now that the shoe is on the other foot, I often have a hard time delegating and asking others to do things for me...I've been the employee for so long, its hard to get used to being THE BOSS. But even in more relaxed residencies where the attendings have you call them by first name there is still a chain of command and you are expected to do what the attendings ask for...this isn't a surgery thing, but rather a simple fact that there are bosses and there are employees in this world. And there are very few people who don't have to answer to someone.

 

[Castro Viejo]

It's not only that they're collectively my "boss."

They're teaching me something that's the foundation for my entire career. So if they ask me, as a Chief Resident, to make sure I go and digitalize every colostomy we have on the General Surgery service, you'd be damn right that I'm going to go personally to do it myself.

It's a sign of respect in my opinion and doing as they say fulfills my end of the deal. They teach me, I do for them. Surgical training is as simple as that. My interns do for me, I teach them in the operating room.

The problem I see in the newer crop of General Surgery residents (granted, this is a narrow viewpoint from a New Yorker who's in a community program but has rotated out through several academic programs as a senior/R4 Chief resident) is that residency training has become more like graduate school. Everything is supposed to be spoon fed. No one wants to take the initiative and crack open a textbook and read for themselves. So residency training here consists of a bunch of interns who come LATE to our 6AM rounds, Dunkin' Donuts coffee in their hands, and "working" as if they're a bunch of grad students at the local college. It's ******ed. If I need an intern, I'll just drop on by the medical library or the cafe in between my cases and find all of them just sitting there. They're "entitled" to be educated, and that attitude gets them nowhere with the majority of attendings I know here in New York.

Maybe it's different in the rest of the country, but I doubt that.

Some med student at UVa was telling me, "It's great there. We address the attendings by their first names. They really take an interest in us." I'm sure that's true. But I'll bet that "Irv" is gonna kick your *** if you don't do as he requests. I was told by one of the fellows there that "Ken" ripped a new butthole into him when something got messed up.

 

[dynx]

No need to "find" a pair, had them all my life.

It's not "brow beaten sheep" THE ATTENDINGS ARE OUR BOSSES. I don't know why the chain of command is so hard to understand for some people.

No different than when a Chief asks you to do something. You don't make excuses, you say "Yes Sir/Mam" .

I know people with this attitude think it's "ballsy", but really it's just childish/lazy.

In my experience those with that attitude and the "how is that educational, waaa" attitude have never actually had to work for anything in their life and have no concept of earning anything or putting your time in. It's no different in real life, in the military or the factory. The boss is the boss.

Yes Sir/Mam will take you a long way in residency. Just remember that because the attendings/chiefs have earned the right for you to say that.

It may not be that way everywhere, but at least here the attendings/chiefs never ask us to do things that they wouldn't do/haven't done and we are not their scut monkeys. If it is different where you are at I am truly sorry for that.

I can agree with most of this post and the key difference here is the word "ask". Someone asks me to do something, Im more than happy to go out of my way to help out. But if you'd like me to do something over and above, the request better start with "could you please..." and end with "thank you". I extend this courtesy to others, and its a respect that has been extended to me in every other job I've had in my life, and with a little re-direction, its one that attendings get used to giving even to residents. Maybe your attendings always approach the residents at your program with respect, if so, fantastic...you're a lucky guy. However, I think that many other people have multiple experiences with the exact opposite situation.

 

[Dr. V]

I can agree with most of this post and the key difference here is the word "ask". Someone asks me to do something, Im more than happy to go out of my way to help out. But if you'd like me to do something over and above, the request better start with "could you please..." and end with "thank you". I extend this courtesy to others, and its a respect that has been extended to me in every other job I've had in my life, and with a little re-direction, its one that attendings get used to giving even to residents. Maybe your attendings always approach the residents at your program with respect, if so, fantastic...you're a lucky guy. However, I think that many other people have multiple experiences with the exact opposite situation.

Well I do have to admit that 99% of the time it's phrased as a request more so than an order. It usually starts with "do me a favor, make sure patient X gets Vanco instead of Ancef preop" or something like that.

Yes our attendings are very nice to us in that regard, chewings are usually well deserved and we are treated well so it DOES make it much easier to say Yes sir/mam and make sure you take care of it. It would get old if it was phrased as an order/because I said so tone 100% of the time. I would still do it because that's how I was raised, military family and working in a factory 12 years before med school, but I wouldn't like it.

A good bonus is most of the time if it's a request like that they will tell you their thinking behind the change/request so you learn from it too most of the time.

At the same time, I am sure after a couple of times of things not getting done the attitude would likely change. I'm not going to find out LOL.

 

[JMarshall]

This has been a useful post, lost of good advice for us soon-to-be interns. I was wondering if some of the residents could post some more specific stuff to learn before we start. A few things I am interested in are:

-Most common pages/ward emergencies/complications and how best to handle them
-Most commonly used med dosages to memorize

Thanks, and keep the good stuff coming.

 

[geekgirl]

1. look things up that you don't know.
orders, doses and such will come to you within the first week. you will be experts at dosing pain meds, zofran, gi proph, etc. but when you don't know - LOOK IT UP (from a reliable source). it is forgivable not to know the answer. it is unforgivable to f*ck up an order cause you're too lazy to look up the right answer. yes, you need to renally dose certain medications. yes, that information is available on micromedex. take the time to look.

2. details matter.
i think many people get into this job and do not feel appropriately dedicated to the sh*tty details of their service. these jobs while thankless, annoying, and requiring of a certain level of OCD actually matter. you will put someone in renal failure with meds, you will cause bleeding - sometimes with horrific outcomes if you overanticoagulate. you will miss big things if you do not constantly patrol the orders, the patients, the flowsheets, the studies you ordered, EKGs, culture data.
you, the intern/junior, are the keeper of details and the keeper of organized data. you may not know what to do with said data, but your seniors will. so make sure you have that data.

3. don't ask anyone to do a job you would not be willing to do yourself.
sure, you are busy. but asking the nurse/med student/ancillary staff person to push meds, do bizarre wound care, draw labs, do studies should all be tasks that given the time, you would also be able or willing to do. (i.e. do not **** on other people and always pull your weight). if they are busy bagging the patient, you titrate the pressors. do not just stand there and watch. participate.

4. agree with previous posts - "i'm just crosscovering this pt", "i don't know what the wound looks like, vitals are, etc when calling a consult or reporting to a senior/attending" is NOT acceptable.
collect all your data, pull your mind/story together, and creat a plan BEFORE calling seniors, attendings, consultants. as interns it is very tempting to just DO - i.e. cross things off the eternal "to do" list. but take a moment and think, organize your thoughts, etc before acting. this will save you much grief and spare you backlash.

5. in keeping with 4 above - always take a moment to think before acting. even in a crisis. there is always a second or two to assess the situation before acting.
the hospital, the staff/nurses/etc will often look to you in acute situations for guidance. do not lose it. do not react to their emotions. because if you participate in the frenzy, you will lose perspective on what is going on. their job is to ring the alarm bells, your job is to synthesize the data and figure out the next step. do it calmly.

6. everyone is a saboteur (i.e. trust no one).
while passoffs may sound reasonable and patients may have already been assessed - always check for yourself. of course, this is not always possible on a huge service. but start to look for statements that ring alarm bells and assess for yourself.
e.g. "yes, this dude is fine. s/p lung tx coming in with low grade fevers, BP was a little low (SBP 70s) but he got some volume and is looking ok. well, he is a little tachy but overall fine" - translation septic, sick as ****, tanking but i wanna go home and am ignoring these signs.
or "s/p colectomy, does have some heart probs - oh, i don't know, some heart history. c/o a little SOB but looks non-toxic. just on a little O2" - translation flagrant CHF/MI in resp failure on NRB needs to be intubated.
trust no one. and if you do trust, know who you can and more importantly who you CAN'T trust. even nice people miss things. and your *** is the one on the line when the patient tanks. no one cares that someone else did the workup or signed you off the lemon. you are responsible if you were there when the bad event happened.

7. never be afraid to ask for help. never be afraid to ask for help. never be afraid to ask for help.
as mentioned above, do not go running to others the second things get hard - but if you find yourself uncomfortable in a situation, beyond your skill/knowledge set figure out why and then figure out the next appropriate person to advise you. it is acceptable to feel/look stupid for asking for assitance, it is unacceptable to let a patient die/crash/whatever secondary to ego. these are people. what would you want done for a loved one of your own? i have seen bad outcomes from this type of situation - it is ugly. know when you need help.

8. have fun. be an optimist. no one likes a crank. no one likes a whiner. no one likes a weasel or a backstabber. people like to be around fun people. happy people. non-complainers. your people skills matter. and when it is beyond you to be pleasant - then just be quiet.

the rest of the stuff - doses, orders, skills, etc all come in time. but retain your common sense, composure, and humanity. it goes far in the hospital. and enjoy your time off - that's how you remain sane.

 

[Mango]

Advice to interns from a PGY4 Gen surg resident (in addition to all the good advice above):

1. Ask questions! When a nurse calls and says "Can Mr. Smith have some Zofran, he's nauseated?" The answer is never "sure." Ask the vitals, ask has the pt been vomiting, ask about other episodes of N/V, you get the point. Often times the RN is so focused on symptoms, they can miss the big picture. Diagnosing the problem is YOUR job. You never want to blow off the call at 2am for nausea that turns out to be d/t hypotension related to massive hemorrhage (I got that call once, and had I not asked the vitals, I wouldn't have caught it).

2. Go see the pt! This avoids problems listed in item #1. If you lay eyes on a pt, you will better asses their overall condition. Often times numbers hide real problems. For instance - pt states he's short of breath, but RN says "He's sating 96% on room air, I think all he needs is a breathing treatment." You go see the pt and find he's tachypnic around 30, and his chest tube that was supposed to be on -20cm H20 suction, has no suction applied to it. This happened 2 nights ago to me; had I not seem the pt, tension ptx was on the way.

3. Write a note! When you are on call, or even during the day - if you see a pt for any reason, write a note in the chart. If you don't you weren't there. When the pt crashes at 6am and the day team wonders what your *** was doing in bed all night - you can say with confidence - he was fine when I saw him.

4. Dictate charts when you D/C the pt. It's been said, but it's worth repeating.

5. Make a list of your pts outstanding cultures and update it each day, outstanding path reports too. Also know what day they are on their abx. The star intern is the one who says to the chief or attending on rounds "Mr. Smith's cultures came back as E. coli and we're on day 3 of Zosyn, do you want me to narrow his coverage to Cipro?" That's the kind of thing you should be able to do.

6. Teach the med students in your spare time. 3rd years should be taught the proper way to write notes, change dressings, roundsmanship, and importantly how to behave in the OR. Many of them have not been taught the etiquette we all think is common knowledge.

7. If you're planning to do research year(s), plan early. Grants like the NIH loan repayment (up to $70 grand off your student loans for 2 years of research) must be sent in the fall before you start doing research. So plan accordingly, these are opportunities you'll want to take advantage of.

8. Call your consults when you order them, and know the pt's history before you do. You sound like an idiot when they start asking you questions and you know nothing. Also, if you order a procedure (like interventional radiology, or cards), know why the attending want the study. The worst response is "because my attending says so." That will earn you no points, and may garner a call from the IR attending to your attending, again making you look dumb.

9. Call up the ladder!!! If you are in over your head, fill the proverbial boat. You do not want to put this off. Even if your senior or chief is an ***, call them every time a pt's status changes. Afternoon rounds are not the time to tell your chief that a pt is tachycardic and you're just starting a third LR bolus!

10. Don't sign out crap to your peers. The night float team (or night call, whatever you've got), is not your bitch. If a CT was done at 4pm, don't sign out at 5pm that it needs to be followed up. If a pt walks in the door at 4:55pm, admit them. It's your pt. You'll understand when you're on nights and faced with that intern who's too lazy to do his own crap and just wants to "clock out" as soon as possible. Night float systems are not supposed to make surgery shift work. You should sign out when you are done with your work, not when the clock strikes 5!

That's just a start, I may think of more. Intern year was fun, I thought. Most of us crazy enough to go into surgery will love the hard work and rewards of intern year. Still, I'd rather not do it again...

 

[Mango]

I already thought of two more:

1. Don't step on other services toes. If the pt has a pain consult, have the RN call them to adjust the PCA pump. Likewise if the endocrine team is involved and you get called about an insulin dose, tell the RN to call endo. Too many cooks, and all that...

2. If you are called on a pt that is not your responsibility, ask if it's an emergency! One morning an RN who was new so she didn't understand the system kept calling the wrong residents about a blood sugar of 30. If just one intern had asked what the problem was and ordered D50, the pt would have been ok. Instead he ended up in the ICU intubated.

 

[Dr. V]

Very good stuff above.

Might I also add when you are asking questions when called always ask what the patient had done. It makes a HUGE difference in post operative management, a colectomy and gastrectomy have different issues to worry about. Lists are big, if you don't ask you WILL get a patient mixed up and end up doing something like telling a nurse it's ok to put the NG tube back in on a fresh gastrectomy anastomosis POD 0. The team WON'T be happy.

2. I will echo never do anything you are not capable of doing, don't go cowboy on anybody. It's OK to call for help, that's what your Sr.s are for and believe me they would much rather you call them sooner rather than later if you are having trouble.

3. This one may not need to be said, but after some of the things I have heard, well here it is. If someone is bleeding hold pressure (holding pressure is NOT bundling laps/dressings on the wound). Don't panic. Stick a finger on it/in it, grab the artery etc. remain calm and have the nurses call your Sr. That seems elementary but I have heard stories of residents (not just interns) that kinda freaked at significant bleeding and didn't do either effectively. A little blood looks like alot, but the main thing is to stop it if you can and a finger works wonders. Remember most of the time even if you don't know how to stop it you can hold pressure adequately until help arrives.

 

[SocialistMD]

Be wary of PRN orders. A lot of times you (or your senior) will write orders for things so as to avoid the stupid 2am page. On all post-op PRN orders (except pain control), I put in a 24 hour time limit, so if the problem happens after POD 1, someone is notified. It may be a little annoying, but it sure beats responding to the code and calling your attending to tell them their patient just died. That was my only M&M to date (knock on wood); I did an open chole on a guy who had his NG d/c'd on POD 1 because he looked good and was passing gas. He developed nausea on the night of POD 1. His nurse gave him Zofran because it was ordered prn and didn't call the on-call intern. He vomited, aspirated and died. Had the intern on call been called about his nausea, she would have gone to his room, seen him blown up like a balloon and placed an NG. If not for my stupid PRN order, he may still be alive today.

 

[tonyjerry]

thanks for all the good tips so far. i was also wondering what you suggest to keep in your white coat. sanford, washington manual, etc?

 

[njbmd]

It's not only that they're collectively my "boss."

They're teaching me something that's the foundation for my entire career. So if they ask me, as a Chief Resident, to make sure I go and digitalize every colostomy we have on the General Surgery service, you'd be damn right that I'm going to go personally to do it myself.

It's a sign of respect in my opinion and doing as they say fulfills my end of the deal. They teach me, I do for them. Surgical training is as simple as that. My interns do for me, I teach them in the operating room.

The problem I see in the newer crop of General Surgery residents (granted, this is a narrow viewpoint from a New Yorker who's in a community program but has rotated out through several academic programs as a senior/R4 Chief resident) is that residency training has become more like graduate school. Everything is supposed to be spoon fed. No one wants to take the initiative and crack open a textbook and read for themselves. So residency training here consists of a bunch of interns who come LATE to our 6AM rounds, Dunkin' Donuts coffee in their hands, and "working" as if they're a bunch of grad students at the local college. It's ******ed. If I need an intern, I'll just drop on by the medical library or the cafe in between my cases and find all of them just sitting there. They're "entitled" to be educated, and that attitude gets them nowhere with the majority of attendings I know here in New York.

Maybe it's different in the rest of the country, but I doubt that.

Some med student at UVa was telling me, "It's great there. We address the attendings by their first names. They really take an interest in us." I'm sure that's true. But I'll bet that "Irv" is gonna kick your *** if you don't do as he requests. I was told by one of the fellows there that "Ken" ripped a new butthole into him when something got messed up.

This is exactly my findings too. There is something about people coming into residency expecting that they are going to have their hands held and everything handed to them. I am very proactive about strong teaching but that teaching is largely around what is NOT "in the book". I never asked anyone anything that I couldn't look up myself and was always pissed at myself when an attending directed me toward a paper that I should have read in the first place. It was difficult but it becomes easy with practice. More than one time, I have peered over the glasses in the OR and said, "We can see that Dr. X isn't keeping up with his/her reading by that question."

The statement in bold, don't believe it. In some things Va is pretty laid back and the attendings have loads of respect for the residents. Make no mistake, I never addressed my department chair by anything other than Dr. K even though he took me fly-fishing on more than one occasion.

 

[TraumaHamster]

How to handle:

1) hypoglycemia (if I run to grab something to eat in btwn. cases- when I forgot to bring something with me - will i be offeding anyone higher up the ladder?)
2) urine (not drinking enough leaves you dehydrated, drinking what you need...., holding things in for too long --- uti, pylo; diaper?)
3) If I saw someone higher up the ladder do something wrong -- contaminate the field, mistake one organ for another --- do I say anything or keep my mouth shut?? What if I think it will harm the patient?
4) being obedient intern vs. being a push-over -- is there a difference? is there anyone I should not take crap from?

Thanks

 

[Castro Viejo]

1) hypoglycemia (if I run to grab something to eat in btwn. cases- when I forgot to bring something with me - will i be offeding anyone higher up the ladder?)

No one's gonna get offended if you eat. You're human after all. But here's the catch, are you eating when it's time or are you just eating because you want to?

Here's a clear example of the WRONG time to go eat something. You're in between cases. Just finished off a case. After the nurse and the gas man takes the patient off to the PACU, you run to the cafeteria to stuff your face. MEANWHILE the PACU nurse is paging YOUR attending for postop orders. Bad move. AT THE SAME TIME the preop nurse is waiting for SOMEONE to write their first assistant note, mark the patient, or do some other stupid preop nonsense just for the patient to be taken into the room. In some places a gas man won't even see your patient in preop unless you or the attending have said your hellos and completed your preop ritual. Double bad move. Also if you've done all the preop stuff and the next patient's ready to go, don't make the assumption that the turnover is going to be 45-60 minutes. It almost always is, but I'd check with the main desk or go over to the room yourself to see. If things haven't even been taken down by the turnover staff, you probably have about 30 minutes left. Check in with the gas man and see how long it may take. Don't just assume and have an hour long lunch. The situation you want to avoid is being paged back to the OR because your patient is already tubed or your attending is pushing the patient into the room himself. That's not cool.

2) urine (not drinking enough leaves you dehydrated, drinking what you need...., holding things in for too long --- uti, pylo; diaper?)

You know your bladder. If you're the kind who drinks a bottle of water and needs to pee in about 60-90 minutes, then don't drink a whole bottle of water right before a Whipple.

3) If I saw someone higher up the ladder do something wrong -- contaminate the field, mistake one organ for another --- do I say anything or keep my mouth shut?? What if I think it will harm the patient?

Speak with that higher-up in private. Same if a lower-down did it -- just because they're lower on the totem pole doesn't mean you can scream at them.

4) being obedient intern vs. being a push-over -- is there a difference? is there anyone I should not take crap from?

It's different everywhere. Learn the power structure and the hierarchy. Generally it's not a good idea to crap on someone, but occasionally it happens. Just make sure you're not crapping on the wrong person or you'll have meeting after meeting with the school psychologist about your "anger management" issues.