I asked a simple question to my colleagues on Twitter yesterday.
Thanks to all my colleagues for their amazing responses! This list is almost the curriculum for a course on how to do well (and be well) as an intern.
Enjoy…and take notes!
I asked a simple question to my colleagues on Twitter yesterday.
Thanks to all my colleagues for their amazing responses! This list is almost the curriculum for a course on how to do well (and be well) as an intern.
Enjoy…and take notes!
Like most of you, my New Years resolutions in past years have been something like “Exercise every day” or “Eat fruits and vegetables with every meal.” And, I bet that you had the same experience I did… a few weeks of “success” and then they seemed to fade away. The problem with these kinds of goals are how they are structured. They end up being “either-or” goals … you are either able to do them or, more often, you miss a day (or two… or three) and feel like a failure.
It’s a simple, but very powerful concept. Set your goal as a destination… as a “lighthouse” in the distance, and then head in that direction every day. As Ryder Carroll explains, “When goals are lighthouses, success is defined by simply showing up, by daily progress no matter how big or small…”
So instead of the usual New Year’s Resolutions, pick a few “lighthouse goals”. Write them down and keep track of how you are doing (every journey needs a map). This can be as simple as one piece of paper for each goal, but I am such a fan of the Bullet Journal, I hope you consider using it.
When you get up every morning think about how to move towards your goal(s). If you veer off course, that’s part of the journey…. look up, find your lighthouse, and correct your course. Every once in a while (maybe monthly?), look at the progress you’ve made and celebrate it! If, on the other hand, the goals you originally chose don’t make sense for you any more, pick some new goals, draw a new map and start over.
Potential New Year “Lighthouse” goals
Today I have the incredible joy of talking to the medical students on our rotation. No agenda, just a conversation that they requested for some “advice”. They just started their surgery rotation last week and it’s their first rotation. First rotation, beginner’s mind, unbridled enthusiasm… it is so wonderful!. I decided I would come up with what I wish someone had told me at the beginning of my rotations…
Be mindful, deliberate and excited about learning.
This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.
Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat, keep on a piece of paper in your wallet or on your wrist
Learn about the practice of mindfulness. Mindfulness has been shown to be effective in decreasing stress and may help to prevent burnout. It’s not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)
Learn to keep a “beginner’s mind”. When I was a student on core medicine I had a senior resident that showed me what beginner’s mind looks like. It was 2am and I was tired. We were seeing a gentleman at the VA hospital for his diabetes, hypertension and some electrolyte abnormalities. I presented the patient to the resident and then we went to see him together. He had a rash, which I thought was so insignificant that I didn’t even include it in my presentation. But, instead of scolding me, this resident got excited. Yes, you read that correctly, 2am and excited about a rash – because he didn’t know what it was. (This next part will date me, but it’s a great example to make us grateful for the access we have to information now). He called security and had them open the library. We spent a wonderful hour looking through books – like a treasure hunt when we were little kids – until we found the rash in one of the books. We were laughing, excited and couldn’t wait to get back to start the appropriate therapy.
Understand what you are going to learn (the big picture)
On every rotation, you will be given a list of learning objectives. By all means, know them, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).
You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.
Develop a system for lifelong learning now
Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.
The practical points on how to develop a system to learn during your rotation are here: How to Ace the NBME Shelf Exams: How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards, but the key points are summarized below:
Take care of yourself.
Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Come up with what is important for you and make a list. Seriously. Make a list of what you find helps you stay on track and then check it off every day. Look at it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.
Don’t forget to take a “Sabbath” every week. True time off is critical for recovery from this stressful work.
If it gets too hard, seek help. It’s a sign of strength, not weakness, and most (if not all) of the people around you have been there.
We have the most amazing job on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you get to take care of another human life with the goal of relieving their suffering. What could be more important than that?
Starting medical school is one of the most exciting moments in a physicians career… but it can be a little daunting! This talk is one I gave recently to the college students in the Baylor College of Medicine Summer Surgery Program. In addition to talking about how medical school is different from college, I also included my top 10 tips for successfully making this important transition.
The “clean slate” of a new year almost always leads us to think of resolutions … things we could change to make our lives better. This is a great time for reflection to realize what you have accomplished, where you’d like to be in a year, and what changes you need to arrive at that goal. I just finished reading Making Habits, Breaking Habits: Why We Do Things, Why We Don’t, and How to Make Any Change Stick by Jeremy Dean which provided some useful ideas about making resolutions.
Know why you want to make the change
“There has to be an ultimate goal that is really worth achieving or the habit will be almost impossible to ingrain.” Jeremy Dean
Let’s take one example – losing weight. It’s fine to say you want to lose weight… but why? Wanting to fit into your clothes is not a trivial reason, but will it really motivate you when it gets tough as much as these?
What’s important is that you find reasons that resonate for you. Do a little research and write down why you want to make the change. Plan to review this, and revise it when needed, on a regular basis.
Make the resolution then make a plan.
To continue the losing weight example, what are the specific new habits you want to develop? Are they “SMART” changes? (Specific, Measurable, Attainable, Realistic and Time-Based). For example…
Develop the “what if” plan.
The next step is to imagine all the things that might derail you and write down a specific plan for each of them. This will be an ongoing process… as you come up with new excuses to not follow through with your new habit, add it to the list.
Back to the example of losing weight….
“Making healthy habits should be a voyage of discovery.” Jeremy Dean
Self-monitoring is critically important to maintaining a new habit. It doesn’t matter if you use an app like My Fitness Pal, a calendar, a spreadsheet or a system like the Bullet Journal… stay accountable by keeping track.
As the habit becomes engrained, change it a little to keep it interesting.
Working out with exactly the same routine quickly becomes boring. It’s one of the reasons people love group classes like spin classes – the instructors are always changing the routine. Be mindful and creative… but stay out of ruts!
“Making or breaking a habit is really just the start. To develop a truly fulfilling and satisfying happy habit, it’s about more than just repetition and maintenance; it’s about finding ways to continually adjust and tweak habits to keep them new; to avoid mind wandering and the less pleasurable emotional states that accompany it. There is great enjoyment to be had in these small changes to routines. When life is the same every day, it gets boring.” Jeremy Deans
Looking for inspiration? Here’s a list of New Year’s Resolutions for medical students, residents and busy docs. Pick 1 or 2 and start working on your plan, your what-ifs and how you will monitor them!
As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our workload. It is difficult to look forward to the dawn of the next work day.
Medical journals and blogs label this as “physician burnout” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead, we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.
Instead, we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days — interminably.
Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:
Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative, and it’s necessary.
Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.
Drink water throughout the work day.
Go to the bathroom when it is time to go and not four or even eight hours later.
Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.
Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.
Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.
Weep if you need to, even in front of others. Holding it in hurts more.
Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.
Learn how to say no gracefully and gratefully — try “not now but maybe sometime in the future and thanks for thinking of me.”
Celebrate being unscheduled and unplanned when not scheduled and planned.
Get away. Far away. Whenever possible. The backyard counts.
Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.
Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.
Start your work day on time. End your work day a little before you think you ought to.
Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.
Take a day off from caring for others to care for yourself. Even a hug from yourself counts as a hug.
Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.
I’ve written before about what to do before medical school starts, how to study in medical school and strategies for succeeding in the basic sciences. But how do you put this information about organizing your studying and your day into a system that works? Everyone will have variations on how they do this, but there are some fundamental principles that apply to all.
Don’t get behind
From day one, the material matters and, from day one, it is voluminous. If you get behind, it’s really hard to catch up.
Study, don’t just read and reread.
You have to actively engage this material and review it (multiple times) to really learn it. You are no longer studying for a test, you are studying to take care of other people. The SQ3R method is used by many students, but there are other systems as well. What is important is to develop a system that works for you. One tool used by many students is Anki, software that allows you to create electronic flashcards to review key points.
Use going to class as time to “study”
One of the important components to active learning is to review the lecture material before it is presented. This is the opposite of what most of you experienced in college, but it’s key. Survey the handouts or slides and make a list of the important points to be covered. Stay actively engaged.
p.s. You can’t learn medicine if you are on Facebook in class.
Create a summary page for each lecture
Include the big concepts, and key points. Include specifics that are stressed by the professor, but avoid listing all the details. You may choose to hand write this, but most of you will come up with an electronic format and will organize the class notes, and your summaries using One Note, Growly or an equivalent software. Although your personal notes are fine on the cloud, don’t put copyrighted material or your professor’s slides where other people can see them (it’s illegal).
Begin with the end in mind
In the long term, what you are learning (yes, all of it) will be applied to taking care of patients. In the slightly less long term, you will be tested on this information on the USMLE Step 1, a high stake exam and the first part of your medical license. Although some dedicated time to study for Step 1 is important, having a system to really learn the material in your basic science courses is by far the best way to do well on this exam.
Don’t sacrifice sleep.
If you don’t sleep you don’t learn as well. Organize your schedule so you get at least 7, but preferably 8 hours of sleep every night.
Eat well, play hard and stay connected.
Clay Goodman,MD the Associate Dean of UME at Baylor, tells our first year class that the first year of medical school is a 60 hr/week job. They need to get up in the morning and “go to work”, using the afternoon and evening to study. He then points out that if they work 60 hours and sleep 56 hours (8 hours a night) they still have 52 hours to work out, spend time with family and friends and do whatever else they want.
So, what should you do the first day of medical school?
Here’s what your schedule might look like…
The night before – pack your breakfast for the morning break and lunch for the next day. Review any posted slides – survey them to understand the “big picture” and use them to start your summary of the lecture. Write down what you don’t understand from the slides (yes, at this stage it may be every line… but that will get better!).
7am – wake up (If you prefer morning workouts, you can get up earlier and workout before class)
7:30 Grab a piece of fruit or a smoothie if you don’t like to eat an early breakfast. (If you are ok with it, eat the full breakfast now, but whatever you do, don’t skip breakfast)
8-12 Attend class – Stay engaged. Take notes, make sure the questions you asked yourself in the review are answered, raise your hand and ask questions if they weren’t. Eat your breakfast or a snack at the 10 am break.
12-1 – Lunch with your classmates. Play foosball, talk, or just eat, but take a real break.
1-5 Study. One hour of studying for each hour of class is about right for most people. This may need to go until 6 or 7 if you have afternoon labs.
7 – Workout and then make and eat dinner. Working out is an important part of self-care. Exercise is essential to decrease stress and also will help you avoid the “freshmen 10”. Your dinner should be healthy, not processed, and definitively not Ramen noodles. Make sure you have fruits and/or vegetables at every meal.
9-10 Look over tomorrow’s lectures and start your summary pages for those lectures. Once you are a week or two into this, you’ll be adding in reviews of material from previous weeks on a schedule.
10-11 Read a novel, watch TV, decompress.
11 Go to sleep!
You are starting on one of the most amazing journeys any human being can have… enjoy it! Don’t forget to keep a journal and take photos (but not of patients). The first time you actually interview a patient, put on your white coat, hear a heart murmur or take a test in medical school are just that … the first time. Write about the experience.
Let me know in the comments what other advice you have for the students starting medical school this summer!
Like our residents (but not nearly as frequently), my group has started taking “in house” call. For every one who is currently or has been a resident, this is an experience we all know…. and one that’s hard to describe to those that haven’t experienced it. Spending 24 hours on call in the hospital can be emotionally and physically draining, but it has moments that make it a special experience, too.
There are ways to make the experience easier. Here are my top 10 ways to survive (and maybe even enjoy) being on call:
1. Drink water. Put a water bottle in the lounge refrigerator, drink from every water fountain, put your water bottle next to your computer, or come up with other ways to stay hydrated. If you want more flavor, bring a zip-lock with cut up lemons or limes to put in your water or add a splash of fruit juice.
2. Be kind. No matter how stressed or busy you are, knock on every patient’s door and enter their room with the intention to help. Sit down or put a hand on their arm when you are talking to them. Smile.
3. Take breaks. On purpose. No one really expects you to work non-stop for 24 hours and it’s not good for your patients. Deliberately stop to do something else every few hours, even if it’s just for 5 minutes. Go outside for a few minutes for a short walk to catch some natural light and breathe some fresh air. Get a good cup of coffee or tea, listen to some music or just sit. If you want something more active, climb a few flights of stairs, stretch, or even do a light workout.
4. Eat well and eat often. Do not rely on fast food or the hospital cafeteria. By far the best plan is to bring really good food from home. You need to have “comfort” food on call. If you don’t cook, buy really good prepared food that you can look forward to. Make sure you have “plan B” ready if your call day gets completely out of control by having an energy bar (my favorite is Kind bars), peanut butter sandwich or other “quick” food in your white coat pocket.
5. Be part of the team. Notice and encourage the unique camaraderie you share with everyone else who is on call. It’s a small “band of brothers” who find themselves in the hospital at 3am. Be kind to each other, help each other, and use this unique opportunity to get to know someone you might otherwise not get to know.
6. Wear good shoes. If you are in house for 24 hours, bring a second pair that’s completely different (clogs and running shoes for example). Ditto socks. Buy really good socks and change them after 12 hours if you can.
7. Use caffeine wisely. It’s practically essential for many of us at the beginning of the day, but beware trying to “wake up” with caffeine after 2pm. Not to mention that if you “caffeinate” all night, you’ll have that sickly post-call-too-much-caffeine feeling in the morning.
8. Take naps. Any sleep is good sleep on call. If it’s possible, 20 minutes will make you more alert and effective in your work.
9. Make your beeper a “Zen bell”. Use your pager or phone as a tool for mindfulness. When it goes off, take a deep breath, relax the muscles in your face and shoulders and be present. This is a proven practice to decrease stress – try it, it works!
10. Learn. Take advantage of the unique educational opportunity of being on call. The fact that there are fewer people around at night and on the weekends has a real impact on how and what you learn on call. If you are a student or junior resident, you are more likely to be the first person evaluating new consults and admissions. You are also more likely to have one on one time with your senior resident or faculty as you care for patients together. If you are further along in your training, the “down time” on call (if there is any!) is a great time to catch up on reading.
For most people, talking about a 16-hour workday is outrageous. For doctors in training, it may not be enough.
Training doctors is not easy. It’s not just a matter of learning what is in the books or latest articles. Under the supervision of attending physicians, young doctors learn the art of doctoring by staying with and caring for their patients. Because of the work they do while they are learning, resident salaries are supported through Medicare… mostly. That’s another issue, but not unrelated to the issue of duty hours.
Twenty years ago, it wasn’t unusual for an intern to arrive at 5 or 5:30 in the morning, work all day, stay up all night on call, and then work the following day until evening rounds were finished. That meant 36-hour shifts and many weeks with more than 100 hours in the hospital. It was clear that this wasn’t sustainable, nor was it safe.
After much debate, in 2003, the initial duty hour regulations were put into effect. In a nutshell, residents couldn’t work over 80 hours a week (on average) and they weren’t allowed to stay longer than 24 hours. If they worked all night, they had to go home the next day. In 2011, the regulations were revised. The major change was that interns (residents in their first year of training) could only work 16 hours in a row instead of 24. On the surface, this made sense. Fewer hours should mean more sleep. More sleep should mean rested interns and fewer mistakes.
I wasn’t surprised to read the article published by Time magazine entitled “Fewer Hours for Doctors-in-Training Leading To More Mistakes.” This report, summarizing the on line JAMA Internal Medicine article from this week, noted that “interns working under the new rules are reporting more mistakes, not enough sleep and symptoms of depression.” In the same issue, authors from Johns Hopkins reported the results of a prospective, randomized crossover trial comparing the new regulations (16 hr work day) to a 24 hours work day with the next day off. They showed no significant difference in the number of hours the interns slept per week between the 16 hour and 24 hour shifts. However, there was a marked decrease in educational opportunities, a significant increase in the number of handoffs, and less resident satisfaction with the 16 hour work day. Most importantly, both the interns and the nurses caring for patients felt that the quality of patient care was decreased by the 16 hour duty hour regulation.
Why would there be more mistakes? Patient care is usually transferred in the morning (to the entire team) and in the evening (to the resident covering the patients at night). That’s roughly every 12 hours. When a portion of the team is rotating on a 16-hour schedule, it results in more handoffs (usually to fewer team members). Increasing the number of times information is transferred between doctors means increasing the risk of communication errors.
If they are working fewer hours why are they not more rested? The new regulations almost require a “night float” system to insure that the patients are taken care of. Working nothing but nights for one week a month followed by 16 hour days is not conducive to being rested.
Why are interns depressed? Remember, decreasing intern work hours didn’t change how much work there was to do in a day – and most hospitals didn’t respond by hiring more people to help. Interns worry that they are “dumping” on their colleagues because they are being required to leave earlier than the other residents. Less obviously, they are learning to be professionals but are being treated like they can’t “take” the hours of the residents one year above them. The message is subtle but real. There’s also a perception that the quality of patient care is decreased by the new system – which is reason enough for a young doctor to feel bad.
Education is clearly impacted. These studies document what we have all observed on the wards. Interns working 16 instead of 24 hours admit and follow fewer patients. In the surgical specialties, they participate in fewer cases. They also attend fewer teaching conferences.
The solution to this complex problem isn’t going to be easy. It’s an ongoing struggle to balance service vs. education, fatigue vs. experience and, maybe most importantly, how we pay for the incredibly important mission of training doctors.
I’m working hard to be part of the solution – along with everyone else in medical education. We owe it to the future physicians we will train and the patients they will take care of.
I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them: Will I kill or hurt someone? Will I look stupid? What if they find out I’m not as smart as everyone else? Will I get divorced/separated/alienated from my friends? Will I gain weight? How am I going to find time to take care of myself?
What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way. The best way to manage your (healthy) fear is to have a strategy. I’ve written in the past about how to succeed as an intern. But if I were going to condense that advice into three easy rules (for every day except your day off) it would be these:
1. Read at least one section from a textbook in your field every day
2. Learn something (in detail) from at least one patient every day
3. Do something to take care of yourself every day
Read at least one section from a textbook in your field every day.
Your goal for the year should be to read a major textbook in your field cover to cover. You don’t have to buy the physical book. It’s fine if it’s on line or downloaded onto your iPad.
Once you have the book, make a list or spreadsheet of all the sections in all the chapters. For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics. When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).
The real goal is not just to read these topics, but to really learn them. So, when you read, don’t just skim. Read to learn. That means taking notes – and reviewing them.
Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.
Learn something (in detail) from at least one patient every day.
It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service. Make it a daily habit to learn in detail about one patient in your care. It will overlap nicely with your goal to read a complete textbook. When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.
One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher. When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself. Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents. They’ve been there.
Do at least one thing to take care of yourself every day.
This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day. At a minimum, though, pick one specific thing you are going to do for yourself and then do it.
Get Some Exercise