What are some common things you see new Interns mess up?

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Syncrohnize said:
Just as the title says. What is stuff that they commonly mess up and how can we avoid making these mistakes?
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1. As you get more experience can rely on clinical judgment more, but in the beginning, know the guidelines and go by the book (ie just because pneumonia patient 'looks okay' doesn't mean they can go home; what is their pneumonia severity index/CURB-65 score).
2. Show up early and be prepared. In intern world being early = being on time, being on time = being late, being late = very very late.
3. Ask your seniors what worked for them - trust their experience/recommended resources. Find a senior who has excellent notes, esp if you're using Epic and ask them if they can share their templates with you.
4. You won't have time for everything - figure out what MUST be done now, what needs to be done eventually, and what can wait.
5. Go read Crayola's on SDN's posts on guides for interns - this was really helpful, pocket protector saved my white coat 🙂.

Listen more than you talk. Figure out how to present well (pertinent negatives, positives), use a good sign out system - SBAR, IPASS, etc - don't be that intern that makes the senior feel like 'what patient surprise am I going to get tonight.' Know your limits and know when to ask for help. Don't text/call the attending constantly for every little question - look it up. Never want to catch an attending by surprise - update them on the important issues (ask yourself, if I were the attending would I want to know), especially status changes on patients. Answer pages asap. You don't want these going one up because they can't reach you.

Read up on patients before clinic - run things by seniors before precepting if you can. Leave personal issues at home. Don't badmouth attendings/colleagues at work (wouldn't even do this outside of work unless it's with fam/friends you 100% trust). Be nice and appreciative to the nurses/staff that help you. Ask how you can make their life easier (right way to do orders).
 
Ironheme said:
1. As you get more experience can rely on clinical judgment more, but in the beginning, know the guidelines and go by the book (ie just because pneumonia patient 'looks okay' doesn't mean they can go home; what is their pneumonia severity index/CURB-65 score).
2. Show up early and be prepared. In intern world being early = being on time, being on time = being late, being late = very very late.
3. Ask your seniors what worked for them - trust their experience/recommended resources. Find a senior who has excellent notes, esp if you're using Epic and ask them if they can share their templates with you.
4. You won't have time for everything - figure out what MUST be done now, what needs to be done eventually, and what can wait.
5. Go read Crayola's on SDN's posts on guides for interns - this was really helpful, pocket protector saved my white coat 🙂.

Listen more than you talk. Figure out how to present well (pertinent negatives, positives), use a good sign out system - SBAR, IPASS, etc - don't be that intern that makes the senior feel like 'what patient surprise am I going to get tonight.' Know your limits and know when to ask for help. Don't text/call the attending constantly for every little question - look it up. Never want to catch an attending by surprise - update them on the important issues (ask yourself, if I were the attending would I want to know), especially status changes on patients. Answer pages asap. You don't want these going one up because they can't reach you.

Read up on patients before clinic - run things by seniors before precepting if you can. Leave personal issues at home. Don't badmouth attendings/colleagues at work (wouldn't even do this outside of work unless it's with fam/friends you 100% trust). Be nice and appreciative to the nurses/staff that help you. Ask how you can make their life easier (right way to do orders).
Click to expand...

Thanks so much, I was just talking to my friend who was telling me how there was a second year FM resident who got fired because she couldn’t make her own clinical decisions. Once she became a 2nd year in her first week, a patient had a fever and the patient “seemed fine” so she asked the nurse how much Tylenol and they gave it but the patient desat’ed and had to be intubated in the ICU. I just don’t want to be that person.

I feel I’m going to be terrible at this part.

Thanks so much again!
 
exceedingly few interns make a decent presentation, so you'll probably **** that up but work on it.
I'm not your personal antibiotic guide, learn to look doses up and you will eventually learn them.
biggest one, you are an actual physician now you need to have your own plan not just the patient history. I may change that plan, but take a shot at it or you'll never get better.
 
Syncrohnize said:
Just as the title says. What is stuff that they commonly mess up and how can we avoid making these mistakes?
Click to expand...

-Being late
-Being mouthy
-Thinking they know everything
-Not taking criticism well
-Blowing off certain patient complaints which turn out to be extremely important because you don't read enough to know what is serious and what isn't
-Not reading/studying
-Not reading/studying
-Not reading/studying

I repeated the last several times because there is this common complaint that interns don't have enough time to read etc. Of course this is bull$hit. 30 minutes a day will put you ahead of the game and is not asking too much.

An intern in July is as useful as a second @$$hole.
 
One of the biggest things that is fairly important is admissions, especially transfers. Most EMRs can be pretty funky with orders and if someone hasn’t taken a minute to explain, usually yours something (especially labs, imaging orders).

I started internship on trauma surgery and it was this way, totally Wild West. I updated an old guide to the service with instructions for future residents on what to do and when. I think it was helpful, and I survived the month with only a few minor injuries!
 
So unlike my fellow classmates who start vacation in March/April, I’m busy all the way until the end of May (delayed board exams, etc). I figured I’d try and make the best of it and try to learn as much as I can from Feb-May because while I’m above average on exams, I still have a lot to learn clinically and am probably weaker than my peers. I have the 2017-18 MedStudy books, 2016-17 MKSAP reading books (no questions), and the OnlineMedEd Intern guide. I also have The Guide to Hospital Medicine recommended by Dr. Williams of OnlineMedEd. I haven’t been hearing great things about OnlineMedEd recently though. Some interns said his lectures were kind of useless and his intern guide is chalk full of a lot of weird life advice they felt was common sense. All the stuff you really need is free. I’m not sure what to be doing at this point. Like I said earlier, from Feb to May, I’m just trying to make the best of my situation.
 
Syncrohnize said:
So unlike my fellow classmates who start vacation in March/April, I’m busy all the way until the end of May (delayed board exams, etc). I figured I’d try and make the best of it and try to learn as much as I can from Feb-May because while I’m above average on exams, I still have a lot to learn clinically and am probably weaker than my peers. I have the 2017-18 MedStudy books, 2016-17 MKSAP reading books (no questions), and the OnlineMedEd Intern guide. I also have The Guide to Hospital Medicine recommended by Dr. Williams of OnlineMedEd. I haven’t been hearing great things about OnlineMedEd recently though. Some interns said his lectures were kind of useless and his intern guide is chalk full of a lot of weird life advice they felt was common sense. All the stuff you really need is free. I’m not sure what to be doing at this point. Like I said earlier, from Feb to May, I’m just trying to make the best of my situation.
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Most important thing you can do ahead of internship is GET SOME REST. Enjoy the break, even if it’s a few weeks or days. You’ll need it.

Do NOT spend it pouring through MKSAP or what have you, you’ll be exhausted and overloaded come July. Fortunately not a ton is expected from a July intern in terms of independent medical knowledge and, particularly, management.
 
Syncrohnize said:
Thanks so much, I was just talking to my friend who was telling me how there was a second year FM resident who got fired because she couldn’t make her own clinical decisions. Once she became a 2nd year in her first week, a patient had a fever and the patient “seemed fine” so she asked the nurse how much Tylenol and they gave it but the patient desat’ed and had to be intubated in the ICU. I just don’t want to be that person.

I feel I’m going to be terrible at this part.

Thanks so much again!
Click to expand...

She didn't ask herself where the fever was coming from?
 
It's hard to know what all goes on in a firing case no matter who you ask, even the PD, Dept, HR, trainee involved.

That said, this sounds like a pretty extreme case. On its face, what it sounds like, and the fact she was a 2nd year and fired for this, tells me it sounds like she really should have known better for this patient, and likely she had other deficiencies that made them not only think she shouldn't be supervising interns on her own, but taking that responsibility away and providing more supervision through remediation wasn't going to shore things up. She may have already been on thin ice and barely scraped by PG1 and this was the last straw.

Not every time a patient unexpectedly decompensates is it a mea culpa. Sometimes it is. I feel confident betting in this case there's more to the story.
 
Be able to accept criticism and actually try and learn from it.

Read something every day, even if just a single article.

If you don’t know something (whether a lab value, an answer to a question you never asked the patient, physical exam finding, etc..) then say you don’t know, NEVER EVER try and make up something or lie... ever.

Don’t be afraid to ask questions if you are unsure of something after you have done at least a minimum quick/basic search or attempt at finding the answer. I am completely ok with, “Hey I just got this patient with PNA and based on current guidelines i should start on Abx X, but they were recently hospitalized so I was going to start Y, do you agree?” As opposed to, “What should I start this PNA pt on?”

Keep some sort of peripheral brain for quick notes/anecdotes... whether it’s a small notepad or notes app on your phone.

Patient presentations.... practice practice practice. In the beginning you will suck and barely be able to get through a awkward coherent story but keep at it.

Everyday, in the beginning, you’ll feel like you aren’t reading enough or learning anything, that’s normal and everyone feels the same.
 
I’m not sure why people above say its ok for interns to have bad presentations. Thats something you need to work on in third and fourth year.

For inpatient medicine interns you need to know a lot of stuff on day 1 to be more useful that a medical student. People who tell you that you can show-up knowing nothing are greatly over-exaggerating. You better at least know how to take a history and physically examine patients and properly document. There was an intern this year that couldn’t do those basic things and was thrown out of the VA.

You also need to start learning in a way that is not about passing a multiple choice examination. Doing MKSAP and Uworld questions is going to give you very little practical day-to-day knowledge of how to do stuff in medicine. I favor selecting topics of interest, e.g. heart failure, copd, syncope, etc. and coming up with your own study guide of what important definitions, history-taking items, exam findings, management, etc. by reading actual medical textbooks on these topics. My first few months of intern year I needed my hand held very little because for each chief complaint, I knew the pertinent information I needed to gather in my H and P to give a coherent presentation and I knew the typical management plans. This all came purely from self-study, so when i was told to go see a new patient in the ER with syncope, I already knew the important information the attending was going to want to know and hence what questions I needed to ask.
 
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Initialy - sick vs not sick (and don’t down play a sick pt to seem like “no big deal”).

As far as presenting- never cared for them much, as an attending I care even less. Modern medicine with EMRs, you collect a significant amount of data prior to seeing the pt, which is used to corroborate the pts history (most of the dx is via the history).

Work on the basic complaints/admissions:
CHF exacerbation (you’ll be pumped on guideline stuff)
COPD exacerbation (life threatening complications - PTX/PE, step up therapy)
HTN emergency
AKI (and on CKD) - indications for HD, workup renal failure
Chest pain
SOB
Sepsis
Syncope/Dizziness/vertigo
Confusion/AMS
Pancreatitis
PNA
PE - indications for tpa/embolectomy, who could you d/c from ED etc
Electrolyte abnormalities with management/workup (hyponatremia, hypercalcemia, hyperkalemia etc)
Etoh detox/overdose (BB/CCB/opioids/BZ etc)
Liver failure/cirrhotic with abd pain

Basics (history, dx, tx) then work your way up to specific management, what could go wrong/typical vs atypical clinical course - expanding differential. Common things occur commonly

Good luck!

Edit: big thing in residency that doesn’t get taught much - the ED is not a burden, their job is not to do an extended workup - I always heard from other residents talking to them about an admission and wasting time asking “well why didn’t you order this or that”. Doing due diligence on proper dispo is important - someone who’s baseline is nl and now confused who is on AC should have a CT hd, which change dispo if found to have a bleed etc. but for the most part, from an IM standpoint, you’re the one who manages the medicine part.
 
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I'd say it depends on the field you're going into, in some degree. In peds, we expect a little less of the knowledge because most schools emphasize the IM part of things. But you should know what resources are available to you, and should know how to calculate numbers for nursery and NICU. Most places will show you this again during orientation, but if you can't do it quickly, you're going to struggle getting everything done in time for rounds.

The biggest problem I see in interns is not respecting the upper levels. They've been through this before, and know the system. If you come in not wanting to ask any questions, you're going to be a poor doctor. If you go straight to the attendings when your senior is available, it's going to reflect poorly on you. If you're spending more than 3 minutes trying to figure out how to put in an order, ask someone how to do it. If you're not sure if you wrote a prescription or med order correctly, get someone to look over it. No one will fault you for asking questions (unless you're asking the same questions over and over).
 
I'll use my "once every sixish months" post frequency to post here because I think this is so important for all interns.

You're going to want to lie, because you're going to forget things. DON'T! Just do not lie. Say "Dr. Hardass, I forgot to write that down", or "I forgot to ask the patient if they smoke", etc. The reason I am asking you these questions is a lot of times because I expect you to have missed asking something, we all do. How you learn is by being shown your gaps. Tell me "I'm sorry, I forgot to ask them that, I'll go back and ask them" instead of "No, they don't smoke" and then I learn they're a 2 pak a day-er.

I hate catching interns lying, especially about lab results. It makes everything awkward because I can prove beyond doubt in 10 seconds you're a liar and now I can't trust anything you tell me.

Trust me, when you ask the patient with 38 medications about their PMH (I'm internal med) you will because of that forget to ask them some other pertinent questions.
 
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