Lessons learned from intern year – part 1

Today’s inane images of the day:

Ogawa Coffee is my new favorite study spot. Mmm, green tea matcha.
I went home for the July 4th weekend to celebrate the wedding of a college friend – it was a delightful, heart-warming event!
Gloomy, albeit still breathtaking view from the roof deck of my apartment complex. Hello, Boston!
Detroit view at night from Ford
There are definitely still moments when I long for the familiarity of home, Detroit and Henry Ford. So why not throw in a view of Detroit at night?

How have 9 months already passed since my last entry? I still remember the excitement I felt to finally have a chance to write an entry during my Emergency Medicine rotation – in fact, I wrote that mammoth of an entry in almost one sitting [it seems that much of my best work has been written during one sitting – when inspiration for an entry comes to me, it hits hard!]. Either way, the burning question on your minds has probably been, “What’s been going on since you started your Anesthesiology training in Boston?”

Readers, you’ll have to stay tuned for another entry answering that question! In short, I finally got over the stress, loneliness and homesickness of moving to a brand new city without a defined support network in-place. I’ve come to see Boston as a second home.

Anyway, as you might’ve guessed from the title of this entry, I’m going to spew musings on lessons learned from my intern year. Keep in mind that I did a Transitional Year internship, which is unique blend of core medicine and elective subspecialty rotations. The only surgical rotation I did was ENT [otolaryngology or Ear, Nose and Throat], but I was rarely in OR that month. So while I think that most of this advice applies to interns in all fields, it may hit closer to home for those of you that have internal medicine rotations.

I thought it’d be fun to write the lessons in a chronological-type order by month, so here goes!

July – Ask for help.

I cannot stress this point enough for new interns [yes, I recognize this post is 2 months late, but perhaps future interns will benefit] – as a newly minted physician, you will have more responsibility than ever. Things that you didn’t pay attention to as a medical student suddenly become important: “Heparin 5000 units subQ for DVT prophylaxis? Or was it 1000 units?”; “Regular insulin IV or subQ for hyperkalemia?”; “Where’s the closest cup of coffee?” [well, maybe the latter was also important to you as a medical student, heh]. Remember that there will always be someone there that you can ask for help – whether it’s your co-intern, seniors, fellows, attendings, nurses, medical assistants – they all have a wealth of knowledge to share with you. Medicine is a team-based sport and we’re all in it for one goal – patient care. So do whatever it takes to ensure you’re providing high-quality care.

August – Nurses [and support staff] are a phenomenal resource – listen to them.

Many nurses have been working on the front-lines for longer than you’ve been in medicine. Some have been there longer than you’ve been alive! Experience matters in medicine and nurses often have experience handling acute issues which you may lack. They also have expertise with certain procedural skills that could help you later in your career. When I was on my anesthesia rotation, I asked the preoperative nurses for their tricks and tips on starting IVs and learned a plethora of techniques. In the Medical ICU, many of our nurses have facilitated running more codes than we have ever seen. During a code, our nurses grabbed the crash cart and emergency medications before I had even processed what else needed to be in the room. Often, our nurses spend substantially more time at the bedside than we can – they are our eyes on the ground. Don’t ever take that for granted, especially when you’re being paged at 3am [after being awake for 24+ hours]. Those moments are when we become resentful of the shrill sound of our medieval devices, but also tend to be tipping points in patient care.

September – Patients will often tell you what ails them – listen to them.

Most patients do not want to be in the hospital [operative word: most]. So when they are stuck in an uncomfortable hospital bed, they are just as motivated as you to figure out how to get back to their lives. Listen to their story. Try to understand what the tipping point was, and what worries them. Don’t forget the context in which this acute event occurred in a patient’s life. Consider that the lost income from missing work may mean one less meal for the family. In instances when cancer may be on the differential, think about how you would handle the diagnosis. How would you want the discussion to go? What kind of physician would you want taking care of you or your loved ones?

October – Burnout is real – don’t ignore it.

By your fourth month as a resident, you may start to finally feel like you have a grasp on things. Putting in admission orders or calling consults are all familiar tasks. You’ve found the stashes of new AA batteries for your pager. The coffee is always flowing. However, you may also start to feel tired. Not the “I’ve-been-working-30-hours” physical exhaustion, but the mental exhaustion of seeing patients die, being asked questions you don’t know the answer to, or realizing you’ve barely had any time to see your loved ones. It’s easy to blame the profession. It’s easy to depersonalize and make superficial connections with your patients. It’s easy to lose the passion for medicine that brought you here in the first place. Don’t let it get to this point. Recognize when it starts to hit and reach out to your support network. Make time for yourself and the things you love outside of the hospital – exercise, art, cooking, whatever. Just don’t let it get to the point of no return.

Making time to go to the gym and reflecting upon my day during my commute to and from the hospital kept me afloat. There were days when I didn’t want to face the world. I felt depressed and alone. I just wanted to stay in bed where it was warm and safe. Those were the days I called my colleagues in medicine to talk about it. Those were the days I went home to see my parents and little brother. These are the coping mechanisms I used to stay balanced and it’s vital that you find yours early on. If you aren’t 100%, you can’t give 100%.

November – Remember that generic feedback you got in medical school, “Keep Reading”? It still applies. 

I took the USMLE Step 3 in November [I know I still haven’t gotten around to a tips for success entry yet… it’s coming], which meant that this particular tip was vital. It’s hard to actually crack open a book as a resident, but it’s not impossible. It’s also completely ok to just read a paragraph or two on Uptodate about a patient’s diagnosis. The main point is to make it a habit. If you learn from questions then buy UWorld Step 3 early on in the year and get through a handful of questions each day on your phone. That’s all it takes.

Through my blogging with Kaplan test preparation [http://medschoolinsight.com and http://residencysecrets.com], I was able to start using the Kaplan Step 3 Qbank early on in the year. I literally did a handful of questions each day [something like 5/day… when I actually remembered to – so it averaged to maybe 20 questions/week] and got through most of the question bank before buying a 1 month subscription for UWorld’s USMLE Step 3 question bank. Between learning from patient care, rounding, question banks, and Uptodate, I felt like I had built a solid knowledge base for when I started my anesthesiology residency.

Now that I’ve started in anesthesia, I have shifted my approach to include textbooks. We take our ITE [in-training exam] in February and the BASIC exam [the anesthesia boards equivalent to Step 1 of the USMLE] in June… although I’ve just started here, time seems to be flying by. February/June will be here before I know it!

December – Never miss out on opportunities to learn.

By December, it can seem like admissions for uncomplicated community-acquired pneumonia or chronic low back pain are mundane. You already know the pharmacy and infectious disease pneumonia guidelines for your hospital and the routine management for low back pain [as well as appropriate opioid-prescribing practices]. While it’s easy to label these diagnoses as “simple,” you can still learn something from the encounter. Residency is a time to be a sponge; you are building the foundation for the rest of your career. Remember to critically appraise labs and imaging studies. Look up review articles and landmark papers related to the diagnoses. Do not take these opportunities slip away.

When I started this entry I had all 12 months listed… but seeing how long this entry is, I decided to break it into two parts. I imagine sometime in the winter [December?] I’ll post part 2!

Current interns, what do you think? What other lessons have you learned since starting residency?

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