Advice to Interns
This column was originally posted in July of 2007.
For the benefit of the new interns, I'll now present my own perspective on internship.
I like to think that my own internship was more like this guy's than the type being advocated amongst some of my fellow medbloggers these days. I was a mediocre medical student, smack dab in the middle of the bell curve, but I ultimately became the best intern in my large program. "How could that be?" you might ask. Simple...I worked harder than anyone else. If you finished medical school at the top of your class, you are ahead of the game and you probably are already anticipating your cushy Dermatology lifestyle. Otherwise, if you want to be successful, you are going to have to turn it up a notch.
Here's a newsflash for you....the most competitive post-residency positions (whether they be Chief Residency slots, rare subspecialty fellowships, prestigious academic appointments, or deluxe private practices) tend to accept the very best residents rather than the slackers. The best residents, in turn, tend to be those who were the harder-working interns rather than the clock-punchers. This first year can really set the tone for your entire career.
On a non-call day, when everything is done then you might as well leave...but preferably not before the attending does. On call nights, there is always something to learn. I read about the medical conditions of my new admissions whenever I had time, because the most effective learning occurs at the point of contact. Memories are hard-wired when you can associate a medical condition or technique with a specific patient situation. I identified residents and attendings who had outstanding skills that I admired, and I learned as much as I could from them. But you aren't learning anything if you aren't in the hospital.
Extra effort counts. Come early, stay late. Be ultra-aggressive about tracking down results of labs and studies. Take the specimens to the lab yourself if it will speed things up. I did my own wet preps of cervical discharges. I went to the micro lab at midnight to personally gram stain the sputum of a couple of my new patients to impress one particularly venerable old-school attending. Obviously, this was before JCAHO screwed everything up, but nobody did those things back then either. I was hardcore.
I stayed up at night on call in the ICU to hand-draw graphs of the anion gaps and electrolyte trends of my DKA patients so I could post them outside the patients' doors before rounds. I spent extra time talking to families and planning discharges. I picked the brains of my fellow residents to find out what the special (quirky) interests of my next month's attending were, so that I could shine on the first day of rounds by demonstrating my newfound interest in inverse ratio ventilation or the nuances of pulmonary artery pressure measurement. One particular attending forbade the mention of trade names, so if a sleepy intern said Lasix instead of furosmide or Atrovent instead of ipratropium bromide, rounds would come to a halt while he got pimped and chastised. I wasn't that guy. Learn what your attendings want, and give it to them without their having to ask you for it. Your job is to make their job easy, and in doing so you will be amazed at how much you learn from the experience. If you hate your job, it's going to show. Be energetic and enthusiastic.
The first two months of internship everybody's pretty much just trying to stay afloat, but by the third month I knew my patients better than anyone else on the team, and I would arrive as early or stay as late as it took for me to make sure that they were well-cared for. I never called in sick the entire year, nor have I ever missed a shift since then.
When I trained, there were plenty of slacking interns. They were easy to identify because they didn't know shit about their patients, and it showed. They got embarrassed by their residents and attendings because they were worthless and weak. I wasn't that guy. I was the guy the residents and attendings wanted on their team. And yes, I was (and still am) married, and my wife was very understanding. Hundred hour plus workweeks are indeed difficult, but it's only for a year. Deal with it.
This first year as a physician is the foundation for the rest of your career. You can use this time to learn more about being a doctor than you did during your entire four years of medical school, or you can bitch and moan about how sleepy you are and how much abuse you are suffering at the hands of your cruel taskmasters. Your choice.
There are plenty of average interns out there. Don't be one of them. Use their mediocrity to make yourself look excellent by comparison.
For the benefit of the new interns, I'll now present my own perspective on internship.
I like to think that my own internship was more like this guy's than the type being advocated amongst some of my fellow medbloggers these days. I was a mediocre medical student, smack dab in the middle of the bell curve, but I ultimately became the best intern in my large program. "How could that be?" you might ask. Simple...I worked harder than anyone else. If you finished medical school at the top of your class, you are ahead of the game and you probably are already anticipating your cushy Dermatology lifestyle. Otherwise, if you want to be successful, you are going to have to turn it up a notch.
Here's a newsflash for you....the most competitive post-residency positions (whether they be Chief Residency slots, rare subspecialty fellowships, prestigious academic appointments, or deluxe private practices) tend to accept the very best residents rather than the slackers. The best residents, in turn, tend to be those who were the harder-working interns rather than the clock-punchers. This first year can really set the tone for your entire career.
On a non-call day, when everything is done then you might as well leave...but preferably not before the attending does. On call nights, there is always something to learn. I read about the medical conditions of my new admissions whenever I had time, because the most effective learning occurs at the point of contact. Memories are hard-wired when you can associate a medical condition or technique with a specific patient situation. I identified residents and attendings who had outstanding skills that I admired, and I learned as much as I could from them. But you aren't learning anything if you aren't in the hospital.
Extra effort counts. Come early, stay late. Be ultra-aggressive about tracking down results of labs and studies. Take the specimens to the lab yourself if it will speed things up. I did my own wet preps of cervical discharges. I went to the micro lab at midnight to personally gram stain the sputum of a couple of my new patients to impress one particularly venerable old-school attending. Obviously, this was before JCAHO screwed everything up, but nobody did those things back then either. I was hardcore.
I stayed up at night on call in the ICU to hand-draw graphs of the anion gaps and electrolyte trends of my DKA patients so I could post them outside the patients' doors before rounds. I spent extra time talking to families and planning discharges. I picked the brains of my fellow residents to find out what the special (quirky) interests of my next month's attending were, so that I could shine on the first day of rounds by demonstrating my newfound interest in inverse ratio ventilation or the nuances of pulmonary artery pressure measurement. One particular attending forbade the mention of trade names, so if a sleepy intern said Lasix instead of furosmide or Atrovent instead of ipratropium bromide, rounds would come to a halt while he got pimped and chastised. I wasn't that guy. Learn what your attendings want, and give it to them without their having to ask you for it. Your job is to make their job easy, and in doing so you will be amazed at how much you learn from the experience. If you hate your job, it's going to show. Be energetic and enthusiastic.
The first two months of internship everybody's pretty much just trying to stay afloat, but by the third month I knew my patients better than anyone else on the team, and I would arrive as early or stay as late as it took for me to make sure that they were well-cared for. I never called in sick the entire year, nor have I ever missed a shift since then.
When I trained, there were plenty of slacking interns. They were easy to identify because they didn't know shit about their patients, and it showed. They got embarrassed by their residents and attendings because they were worthless and weak. I wasn't that guy. I was the guy the residents and attendings wanted on their team. And yes, I was (and still am) married, and my wife was very understanding. Hundred hour plus workweeks are indeed difficult, but it's only for a year. Deal with it.
This first year as a physician is the foundation for the rest of your career. You can use this time to learn more about being a doctor than you did during your entire four years of medical school, or you can bitch and moan about how sleepy you are and how much abuse you are suffering at the hands of your cruel taskmasters. Your choice.
There are plenty of average interns out there. Don't be one of them. Use their mediocrity to make yourself look excellent by comparison.
Labels: internship, tips
posted by scalpel at 7:01 AM
22 Comments:
i enjoyed your post. as a 4th year, i'm trying to step it up a notch and act as an intern. i appreciated your post and i will keep in mind some things you mentioned as i do my sub-I.
any other tips? please post them in a future update on how to be a great intern!
your are a better man than i though i was a very thorough intern and did well in internship and residency.
i admire your ability to compartmentalize and keep your eye on being excellent.
me, i'm crispy around the edges and can't help but sympathize with panda and his views expressed recently on his blog.
i think some are built to handle the circadian disruption well and some are not.
for me there was no difference in internship and residency in terms of the crap and i'm not sure that our training should be done like it is.
that being said i think the US produces the BEST physicians in the world but believe that it is IN SPITE of the system and due to the fact that to get there in the first place you must have jumped higher and farther than most.
i also believe that as the rewards for becoming a doctor are decreased that medical schools will have to lower their standards. i hope i am wrong about this .
cheers.
Thanks for giving a non-"whiney" approach to internship. Just curious, did you do an IM or surgical internship? I believe Panda did a surgical internship which may have skewed his experience. I personally did a medical internship at one of the biggest city hospitals in the US. It was stressful as hell, but I came out of that residency feeling and knowing I was as good a doc as I could be.
P.S. If you're interested in how the APPS fight for the non-ABEM ER docs is going, check out my blog. I'm still reeling from the loss of Flea and Trenchy, so I'm glad to still have you around.
I went to the micro lab at midnight to personally gram stain the sputum of a couple of my new patients to impress one particularly venerable old-school attending.
Dr. House? Is that you? Did you prepare and hang all your patients' drugs, look in your patients' refrigerators and run the MRI scanner yourself too? ;-)
Scalpel and Dr. House aren't the only ones who do gram stains. At my training program, the interns were expected to produce gram stains and AFB stains of patients admitted after the lab had closed. During my Derm rotation, the residents were supposed to get KOH preps of all rashes suspected of fungus (which meant all of them). This is all very low tech, but could make a big difference in diagnosis and treatment.
Is the sleep-deprivation aspect of internship, by design? Is it a deliberate method by which we make better doctors? Or is it simply unavoidable? Or, worse, perhaps a matter of economics more than of training? I've seen some talented, capable and motivated folks give it up, even (or especially) near the end. Would have been good doctors. The ability to go without sleep is valued too highly, imo. Why do we expect this of doctors and not airline pilots? Answer - because the results of stupid mistakes are more starkly obvious for the latter.
Nice post. I wish other interns I know had any amount of patience or drive.
Damn. Why can't I work around folks like you?
Interesting post and great work ethic! Obviously - a patient and supportive wife too. :)
Your anion gap curves for your DKA patients gave me goosebumps! I've been known to draw temperature curves when cooling patients for aneurysm--partly for fun, partly to help predict when to stop cooling and when to start rewarming, based on where the surgeons are.
I think Fred (link) is full of it. In his day they made all sorts of medical errors that were never caught by the lawyers. They had nurses running at their beck and call. They fell asleep and wrecked their cars, they got divorced (in many cased were not allowed to be married), estranged their kids, and eventually pulled in heavy salaries and drove light sports cars for a reward. Others committed suicide along the way. Much of their work was not even peer reviewed and "expert" opinion, often wrong and outdated, ruled the day. There was no internet and no UpToDate. Half of what was in their attendings' heads was already out of date and hopelessly obsolete. The good 'ol days... bah!
Dr. S,
Your assumptions are largely unfounded. The attendings in the university programs where I trained 48 years ago were very well informed, and read every peer reviewed journal in their specialties. True that they couldn't Google a disease and get a lot of hits that may or may not be accurate and relevant. You wouldn't have survived rounds with Professor Major or Professor Delp with your attitudes intact, nor professor Gregory, where Scalpel trained.
Hmmm. Here is my take on internship. I did a 1+4 ER program so my intern year was a "transtional" program, not prelim med or surg. I was already accepted into the ER program when I started so honestly, I did not need to "shine" for any reason other than to to not look like an idiot. I worked like a dog for the three months of floor medicine and three months of surgery that I did - but was clever enough to learn what I needed to so as to not screw up (but honestly, no more than that). I knew I would work harder my second year as an EM resident. Thus, the second six months were spent taking electives with no call - like ophtho, anaethesia, derm, etc. In fact, the second six months were easier than my 4th year of med school! I basically hung out and enjoyed my "freedom". My second year was a different story - 5 12 hour shifts a week in the ER for 8 months out of the year. That was where I "shined". Thus, my recommendation is don't kill yourself in internship if you are already accepted into a 2-4 program! Who the hell would want to do prelim surgery and get your ass kicked 24-7????
Oops - I meant I did a 1+3 program for a total of 4 years, not 1+4.
Let me add the following advice: if you have a good senior resident on an off-service rotation, ASK him/her what they want you to be capable of doing. You might be surprised at what we feel is important for you to know/do IN THE ER AS RELATED TO OUR SPECIALTY.
Also, if it is a numbers game (eg, you need x number of deliveries for the month) I would make sure you got them but you had better damn well be a team-player and do the WORK needed to earn the numbers.
The lazy off-service interns hated me because I wouldn't call them for a delivery if they weren't around. The superstar off-service interns thought I was a great senior resident.
I read The Intern Blues several years ago, and then again last month. My perspective on the issue is limited, but suffice it to say that your post makes for better (and less whiny) reading.
Just sayin'.
I swear you're my father... but that's a very good thing. Thanks for offering the counter viewpoint.
I'm curious how many patients you were caring for at a time. At my program the overnight intern's census is well over 50 most of the time, and often over 70 during trauma season. The ICU resident's census is usually around 30. So I can't imagine having time to make charts of my patients' lab trends, much less go down to the lab and run any tests myself.
Not to mention that my program requires that I leave in time to give myself 10 hours out of the hospital before coming back in to preround in the morning. And I'm not going to lie, because that's a slippery slope I don't even want to set foot on. So, often a number of those hours are spent working from home, because the work simply can't be done in the 24 minus 10 hours you're allowed to be at the hospital. It's hard to be as diligent as I'd like with the work hour restrictions we now have.
I cross-covered a similar number of patients as that. The most patients I ever admitted on one 24 hour call was 17 as a resident, I think I gave 6 to each intern and took 5 myself.
I think we tried to limit the number of new admissions per intern during each callnight to 6, but sometimes they ended up doing 8 depending on the circumstances.
And we had sick patients back then too.
The way it works at my program is this:
The R3 is on call for consults, and spends most of the time in the ER admitting traumas, either to the ICU or the floor. He is the traffic cop for anything potentially surgical that comes into the ER, but does not have patients of his own.
There's an R2 on call in the ICU, who admits anywhere from 5 to I'm guessing around 20 patients, covers anywhere from 5-10 on his own service, and cross-covers another 10-15 from the other team.
On the floor there are four interns during the day for 70 or so patients (two trauma teams, each with 12-40 floor patients), and a night float intern who covers both teams' patients, plus another 0-12 or so from thoracic/vascular. He will get around 2-5 patients directly from the ER, and another 5-10 from the ICU (who may or may not be ready for the floor).
So the night intern, alone, has around 70 patients, and can expect 10-15 admissions/transfers.
The night ICU resident, alone, has around 30 patients, and can expect 5-20 admissions.
Each trauma team has 30-70 patients, with another 5-20 on thoracic/vascular. So the night chief (whose role it sounds like you are using for comparison), is covering 100-140 patients in house.
Just so we're comparing apples to apples.
I did a Medicine residency, so that's not really comparing apples to apples. But transfers don't really count for much. Sure it's more work, but the transferring team writes the transfer note and the orders, and the patient already has a plan. We counted those like half an admission, basically.
To the anonymous commenter whose extremely long and bizarre comment I just deleted, I may repost your diatribe as a guest blogger post of its own, but I've got to have a closer look at it first. Have patience.
I neither have the patience nor the time to read everyone's comments but I do appreciate everyone posting their thoughts. Most importantly, I want to thank scalpel for taking out so much of his/her valuable time and posting this. Incoming interns everywhere would certainly appreciate your post..I know I do! Thanks, again....cheers!
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