What are some good resources to learn the basics of IM residency?

[Konigstiger]

Assuming I match somewhere, I'll probably be an intern in IM next summer, but I feel like I don't really know anything. All my knowledge comes from Anki and STEP II UWorld questions, and I would guess that the vast majority of that is not actually useful for an intern's job duties.

Maybe an unclear question, but is there a textbook, website, or Anki deck or something that can just help me learn the basics of internal medicine residency, like what type of fluids to order, most commonly used antibiotics, what the most common patients you see are and how to manage them, etc.? I feel like I can answer board questions on obscure topics, but I don't have much practical knowledge in regards to managing patients on the floors. I'm not looking to go hardcore in terms of studying ahead, but I would like to see if there are a few things I can learn beforehand so I don't embarrass myself.

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[gutonc]

It's called a Sub-I and internship. Have you not paid any attention on your clinical rotations? Half of what you do in surgery, OB, neuro and psych is just general IM...and that's not even considering your IM rotation.

 

[NewYorkDoctors]

as an intern, you do not need to make any independent decisions yourself. you do not need to know anything other than how to answer pages/calls and how to triage your time as effectively as possible to be as fast as possible.
you do what your attending and senior resident tell you to do. you should focus on getting organized and efficient as a first step.
during rounds, create a check list / check box system.
if you don't drink coffee, then start doing so. if you already drink coffee, get ready to sip it throughout the day.

your job as an intern is not to solve all the patient's problems. your job is to get the work done and let the higher ups make the big medical decisions.

get in early
get night float sign out
tell your senior resident any concerning sounding issues
go pre-round - get yelled at by curmudgeon patients who tell you to come back when you have more experience
start writing the HPI part of your notes so the attending can sign that.. then go back later at night to finish it. do not let note writing get in the way of the actual work. a nice note is cool but acting on the note is even better
during rounds pay very close attention to the order and instructions. write it all down on some checklist check box.
go get those things done ASAP - put orders, call people, etc...
during down time start working on discharge summaries
on call days always be ready for new admissions - take our senior residents lead on "what to do" to start and get that done before going to the attending
don't fret too much about a "perfect note." it's more important to get the action done then write some manuscript . save that writing effort for your research projects.
with all the panconsulting that goes on, be sure to stay on top of what all consultants recommend - inform your senior and attending - and carry those recommendations out before the consultant yells at you the next day
take initiative and if you are unsure ask your senior - please tell me what to do next !

you will learn by "diffusion." once you get the nuts and bolts down in the second half of the year, you can finally begin to apply the big picture thinking process.


toss all of that board question stuff out. once you are an attending, you can be esoteric with things that you never manage in your career to try to impress someone on trivia night (and no one will care). By golly i know quite a few "academic" internists/hospitalists who like to talk about these rare things in books that they never manage as hospitalists. cool story bro!

Lown-Ganong-levine syndrome? no one cares you read that USMLE UWorld question about that. a cardiologist won't care either.

Tangier Disease with the orange tongue? no one cares you read that Kaplan USMLE question. only 100 cases have been identified since 1961!

Tangier Disease - StatPearls - NCBI Bookshelf

gotta get your head outta the books and into the world

 

[sloh]

Assuming I match somewhere, I'll probably be an intern in IM next summer, but I feel like I don't really know anything. All my knowledge comes from Anki and STEP II UWorld questions, and I would guess that the vast majority of that is not actually useful for an intern's job duties.

Maybe an unclear question, but is there a textbook, website, or Anki deck or something that can just help me learn the basics of internal medicine residency, like what type of fluids to order, most commonly used antibiotics, what the most common patients you see are and how to manage them, etc.? I feel like I can answer board questions on obscure topics, but I don't have much practical knowledge in regards to managing patients on the floors. I'm not looking to go hardcore in terms of studying ahead, but I would like to see if there are a few things I can learn beforehand so I don't embarrass myself.

Regular daily reading as you’re taking care of patients starting day 1 of intern year. That’s when the reading and learning will really stick. UpToDate will be your best friend. Learn how to read and appreciate long form content. Studying for boards is very different compared to studying to be competent.

 

[Konigstiger]

It's called a Sub-I and internship. Have you not paid any attention on your clinical rotations? Half of what you do in surgery, OB, neuro and psych is just general IM...and that's not even considering your IM rotation.

Honestly, I feel like I didn't do much at all compared to the residents during third year. I do have more IM rotations coming up this year, though, so I will see if I can gain anything from those.

 

[Elixir6]

You can use Pocket Medicine (or Pocket Outpatient Medicine). Also there is UCSF Hospitalist handbook if you really must read more "practical" books. OnlineMedEd Intern videos look helpful.

I agree with prior long post about being organized, efficient and not sweating notes so much, but I disagree about "leaving important medical decisions to higher ups". You should act as the patients' primary doctor and attempt most all decision making and have some rationale. You shouldn't feel worried about being "wrong" and as long as you ask before you do, no one should fault you.

As the Intern you are in a safe space and should feel supported. The attending and senior resident are there to make sure you take good care of them patient and that they guide all of your medical decision making.

So I don't think an interns learning will be nearly as good if they see themselves as order placing and note writing monkey. Otherwise, if you don't commit to making decisions, after 12 months you will be a senior resident who now has to make decisions without the experience of having made them before.

Just my two cents

 

[NewYorkDoctors]

I agree with prior long post about being organized, efficient and not sweating notes so much, but I disagree about "leaving important medical decisions to higher ups". You should act as the patients' primary doctor and attempt most all decision making and have some rationale. You shouldn't feel worried about being "wrong" and as long as you ask before you do, no one should fault you.

True. but for the first half of the intern year, it's more important about being a good note and order monkey.
the first half of the year is not the time for playing Dr House and pondering if someone's fever, back pain, rash, and LFt rise c ould be Dengue hemorrhagic fever because one read it in pocket medicine.

moreover, having an intern stop during pre-rounds to answer the common patinet questions of

"why am I still here. I have back pain. I have stomach pain. (but conveniently leave out what other doctors told them patient).. why arent I fixed yet? i have chronic pain why? I have this why?" will only stifle the fresh intern in the beginning. I want an ophthalmology consult now for my chronic glaucoma! etc..."

my point is in the beginning one should focus on getting the workflow done and let the attending (primary and consultants) take care of the "executive decisions" if that makes sense.

but for things relative to the patients immediate inpatient care like repleting electrolytes, adjusting sliding scale insulin, inputting consultant orders, talking to case management, changing diet order according to patient preference, etc..... yes those things the intern should learn to be independent on.
usually most interns pick up the flow and speed by the second half of the year. by PGY2 they should be able to work mostly independently for most common cases and only have the attending weight in on the "harder cases" about what exactly to do during rounds.

i guess my point is it is more worthwhile for an intern to learn how to get things done quickly independently (with guidance in the beginning) than it is to be super booksmart

Value of Transverse Groove on the Earlobe and Hair Growth on the Ear to Predict the Risk for Coronary Artery Disease and Its Severity among Iranian Population, in Tehran City - PMC

The use of phenotypic parameters along with other noninvasive diagnostic modality can lead to early diagnosis of coronary artery disease (CAD) and prevent its life-threatening outcome. Recently, the application of head and face components for ...

www.ncbi.nlm.nih.gov

It is well known that ear canal hair portends CAD risk. but an intern pointing that out during rounds in CCU in an acute STEMI patient and delaying ordering the Trital drip is somewhat pointless for all involved.

 

[dgdg]

Regular daily reading as you’re taking care of patients starting day 1 of intern year. That’s when the reading and learning will really stick. UpToDate will be your best friend. Learn how to read and appreciate long form content. Studying for boards is very different compared to studying to be competent.

When you step in as a first day intern, you'll feel like you don't know anything. From a practical perspective, that's probably true. However, you are primed like a sprinter at the blocks, ready to learn a huge amount of practical information rapidly. Don't worry. You are supposed to be taught. You are supposed to learn from others, but also by yourself. You will succeed if you work hard.

I found reading about my patients' conditions extremely useful. Read about your patient's admission to refine your differential diagnosis in order to formulate a structured plan. Read about them again during some down time. Your resident or attending may not catch everything. They are 100% your patient even if early on you feel like you're just putting in potassium replacement orders for everyone.
I remember going through a differential diagnosis using UpToDate with my intern at 2am, leading us to diagnose our patient with bronchial carcinoid even before we had any testing back. It was all history, exam, and deduction. I also diagnosed a patient, who had already seen other outpatient clinic doctors, with systemic mastocytosis. Most of the time your discoveries will more common problems (ex "You stopped your amlodipine") and less complicated, but they are still extremely important to your patient. My point is - the opportunities to 'figure it out' are there, if you look for them.

If you have a patient with a diagnosis that is new to you, read about it as soon as possible to cement that knowledge. Read in UpToDate, your best practical resource. Read a review article. Find a clinical trial. Read something. Be the expert of the day, but always modest. Good physicians and other clinical staff will see what you know and how hard you work.

Actively learning about all your patients will allow you to succeed. Be a sponge. Soak it all up. Your growth will be exponential. If you see enough breadth of conditions in your training, you won't even need to study for the initial certification boards because you've been doing it for 3 years already. If your program is less busy with complex care (more small community based?), then you'll need to supplement for things you haven't seen.

 

[Ubba]

First Aid for the IM Boards. Go through it each year of residency with a particular emphasis on thinking with an "if I were plunked down into a Nowheresville Hospital with no other internists but all appropriate diagnostic modalities available, how would I manage this?" approach. What are the 5-6 most important symptoms to discuss, what labs do I need, what imaging do I need, and what medications will be appropriate if [X] is the diagnosis?

IM is seriously easy to coast through, but your goal should be to be able to be a great generalist Day 1 after residency, and that's eminently feasible if you get started thinking from an imagined position of ultimate responsibility.

First Aid for the IM Boards, UWorld, MKSAP Qs, and Board Basics +/- MKSAP books (the latter of which were designed as cures for insomnia). All you need for resources in residency. Oh, and either Medscape or UptoDate app on your phone.

 

[Elixir6]

True. but for the first half of the intern year, it's more important about being a good note and order monkey.
the first half of the year is not the time for playing Dr House and pondering if someone's fever, back pain, rash, and LFt rise c ould be Dengue hemorrhagic fever because one read it in pocket medicine.

moreover, having an intern stop during pre-rounds to answer the common patinet questions of

"why am I still here. I have back pain. I have stomach pain. (but conveniently leave out what other doctors told them patient).. why arent I fixed yet? i have chronic pain why? I have this why?" will only stifle the fresh intern in the beginning. I want an ophthalmology consult now for my chronic glaucoma! etc..."

my point is in the beginning one should focus on getting the workflow done and let the attending (primary and consultants) take care of the "executive decisions" if that makes sense.

but for things relative to the patients immediate inpatient care like repleting electrolytes, adjusting sliding scale insulin, inputting consultant orders, talking to case management, changing diet order according to patient preference, etc..... yes those things the intern should learn to be independent on.
usually most interns pick up the flow and speed by the second half of the year. by PGY2 they should be able to work mostly independently for most common cases and only have the attending weight in on the "harder cases" about what exactly to do during rounds.

i guess my point is it is more worthwhile for an intern to learn how to get things done quickly independently (with guidance in the beginning) than it is to be super booksmart

Value of Transverse Groove on the Earlobe and Hair Growth on the Ear to Predict the Risk for Coronary Artery Disease and Its Severity among Iranian Population, in Tehran City - PMC

The use of phenotypic parameters along with other noninvasive diagnostic modality can lead to early diagnosis of coronary artery disease (CAD) and prevent its life-threatening outcome. Recently, the application of head and face components for ...

www.ncbi.nlm.nih.gov

It is well known that ear canal hair portends CAD risk. but an intern pointing that out during rounds in CCU in an acute STEMI patient and delaying ordering the Trital drip is somewhat pointless for all involved.

Yeah... I mean, there is obviously a balance. And I agree with a lot of your advice. I'm not recommending perseverating over esoteric diagnoses. I'm just pushing back against this notion of passive learning. You mentioned "you do not need to make any independent decisions yourself" and "get the work done and let the higher ups make the big medical decisions"

Yes, no decisions need to be made without getting advice from senior or attending, and big decisions should always be run by them, but the intern is not a glorified surgery service PA.

All I'm saying is as the intern you should act as the patients' primary doctor and *attempt* all aspects of MDM. Learning knowledge, skills and attitudes will be much enhanced this way.

 

[rokshana]

Yeah... I mean, there is obviously a balance. And I agree with a lot of your advice. I'm not recommending perseverating over esoteric diagnoses. I'm just pushing back against this notion of passive learning. You mentioned "you do not need to make any independent decisions yourself" and "get the work done and let the higher ups make the big medical decisions"

Yes, no decisions need to be made without getting advice from senior or attending, and big decisions should always be run by them, but the intern is not a glorified surgery service PA.

All I'm saying is as the intern you should act as the patients' primary doctor and *attempt* all aspects of MDM. Learning knowledge, skills and attitudes will be much enhanced this way.

First day or even first month an intern that thinks they can make the “big decisions” is dangerous… they are over confident and the dunning Kruger is high… give me the scared clueless intern willing to learn anytime over the overconfident one that thinks that they are ready to be the doctor…the former will be a great physician in the end… the latter? Wouldn’t send my dog to to them.

 

[NewYorkDoctors]

Yeah... I mean, there is obviously a balance. And I agree with a lot of your advice. I'm not recommending perseverating over esoteric diagnoses. I'm just pushing back against this notion of passive learning. You mentioned "you do not need to make any independent decisions yourself" and "get the work done and let the higher ups make the big medical decisions"

Yes, no decisions need to be made without getting advice from senior or attending, and big decisions should always be run by them, but the intern is not a glorified surgery service PA.

All I'm saying is as the intern you should act as the patients' primary doctor and *attempt* all aspects of MDM. Learning knowledge, skills and attitudes will be much enhanced this way.

right. the intern should know which things are "automatic" and do those things. this is how they get better when they admit at night later on in residency.

like... pleural effusion noted for admission. pulmonary consulted not here yet.
Intern should know toadd on LDH labs or draw them to do lights criteria.

AFib RVR new diagnosis - intern should know to get TSH done.

intern needs to learn how to do all of these instant obvious things as seniors and attendings will be annoyed to no end if they hav eto ask about these after the first half of the year.

but for very complex multiorgan issues, best to run things by the senior and attending of course

 

[Elixir6]

First day or even first month an intern that thinks they can make the “big decisions” is dangerous… they are over confident and the dunning Kruger is high… give me the scared clueless intern willing to learn anytime over the overconfident one that thinks that they are ready to be the doctor…the former will be a great physician in the end… the latter? Wouldn’t send my dog to to them.

and big decisions should always be run by them

... Neither said nor implied by my post. In fact, the opposite. I too definitely don't want an over confident intern. All I'm saying is *attempt* MDM. That doesn't mean do something wreckless.

 

[dozitgetchahi]

... Neither said nor implied by my post. In fact, the opposite. I too definitely don't want an over confident intern. All I'm saying is *attempt* MDM. That doesn't mean do something wreckless.

I agree with you.

When I was an intern, a lot more was expected from me than to just be the chart writing and consult calling monkey. Perhaps my program was a bit further on the side of intern/resident autonomy than most, but certainly after the first 4-6 months or so you were expected to be able to get the basics figured out and ordered for a new admit before staffing and to be able to go take some steps to put out basic fires yourself before coming back to run everything by resident/attendings. The intern who was still in “chart writing mode” by 6-8 months in was going to be flagged as someone who was behind.