Starting Internship (I know what you are worried about)

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?

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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.

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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.

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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.

Eat well

Get Some Exercise

Be social

Starting Medical School: Rules of the Road

In the next few weeks 17,000 college graduates will start the process of becoming lifelong students of medicine.   Medical school is a wonderful, but at times difficult experience.  Here are five “rules” that I hope will help with this exciting transition.

 

1. You can drink from a fire hydrant, but you’ll need to learn how.

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  At Baylor (where I teach) we calculate that the first year of medical school is the undergraduate equivalent of 22 hours of course work per semester.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  But these first two years are important; You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.   By the way, sometime during the first month or two of medical school you will think that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c) there is absolutely no way to read all of this material.  But, like everyone who has done this before you, will discover that a) you are just as smart as everyone else (sometimes in different ways, but equally effective) b) nobody made a mistake – you really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

 

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

 

3. Act like a doctor – starting now.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions and how they might be interpreted by patients or colleagues.  It’s no longer acceptable to put anything you want on YouTube, Facebook, Twitter or other social media.  How you dress and act when you are in professional settings will be important.  You’ll learn more specific details about professional behavior from your professors and colleagues as your training progresses, but the core values of medical professionalism start when you enter the profession, which is now.

 

4. Kindness matters.

It is remarkable how our paths in medicine cross over and over again.  The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now.  You and your classmates will be going through classes together (like you did in college), but this is different.  You are starting your professional life together as well.  The camaraderie that results is a gift and is also very important personally and professionally.  Don’t blow off the class events.  Don’t stay home to study instead of going to class.  Go out of your way to meet everyone in your class and really get to know them.  Cultivate and nurture these important friendships.

 

5. Enjoy the journey

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them with words, photos, or drawings.

 

“Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.”

William Osler, from Teacher and Student, in Aequanimitas.

 

 

 

Advice for New Interns

The summer is the time that the roughly 16,000 new doctors in the United States start their residency training. For all new interns, even though it doesn’t feel like it, you are ready!  The first year of medical school gave you the “vocabulary” you needed for this new language. The second year gave you the “grammar.” Your rotations in the clinics taught you the “language”.  Now you get to actually use it every day!

This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories. Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!). These notes and images will be precious memories in the future.

In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship:

Learn from every patient.

As an intern, you will need to know a lot of detailed information on your patients. You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said. If you have a system you developed as a 4th year medical student, great! If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring. In the era of the EMR, much of the information you need can be easily accessed… but not really organized the way you need it. If you have developed a good system that doesn’t require physical cards, please send me a message so I can see it!

That covers the information, but not the learning. Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep. Work on a system that lets you record what you are learning during your daily tasks in a way you can review later. 3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see. p.s. Don’t lose your cards!!!! (HIPAA violation)

Don’t confuse gathering information with studying information. Taking notes is a critical part of learning. Don’t just store chapters and articles in your Google drive… summarize them to review later by taking notes.

Be the doctor for your patients.

This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient. Stop every once in a while and remember that you really are their doctor. Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.

It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”. When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending. What if you were really the only doctor around? What would you do? Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.

Part of being a good doctor to your patients is to recognize your own limitations. You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is.  It’s the right thing to do for the patient.

Be deliberate about learning your field.

From day one, commit to an organized plan of study to cover everything you need to learn in your field. Make a plan to read (and then study to learn) a textbook every year. Make notes that are easy to review, so you don’t have to go back to the textbook to review the material.   Whatever system you use, make it easy to integrate the notes you are making in the hospital (e.g. the 3×5 card on each patient) with your organized study system. Adding articles into the mix is fine – but only after you have mastered the basics. Don’t let reading the latest finding take the place of really learning the material in the textbook.

Be kind and be part of the team.

Hard work is made easier when it’s done with your friends. You will all be tired, you will all be stressed, but be kind to each other. Staying 5 minutes more to help out a fellow intern is an investment that will help both of you. Look for ways to apply the golden rule of internship:  “Help others the way you would liked to be helped”.

Make your bed.

Do this simple act every morning to remind yourself to take care of yourself. Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call. Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own well-being by improving your nutrition and working on your fitness. Nurture your relationships – make your family and friends a priority. Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.

Smile!

You have the enormous privilege of caring for other people and learning the art of medicine. Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.

Congratulations to you for all you’ve accomplished thus far!  Enjoy this incredible journey!

New Year’s Resolutions

Why not take advantage of the first of the year to follow the tradition of making changes?  It’s a good opportunity to take stock of where you are and where you’d like to be a year from now.  Here’s some ideas to think about if you are planning to make some New Year’s Resolutions.

Eat real food. You may not be able to follow all of Michael Pollan’s rules all the time, but you should at least know about them.  Make a resolution that fits your life, but start with a) decreasing processed foods and b) increasing fruits and vegetables.  If you aren’t familiar with the principles of good nutrition, resolve to learn more by reading textbooks, information on line or books like In Defense of Food by Michael Pollan, Food Matters by Mark Bittman, or Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating.

Eat breakfast. There are a lot of reasons this is a good thing to do!  This is an easy resolution for the new year.

Lose weight to a healthy BMI. If you are in the group of people (like many of us) who struggle with weight this is a hard task!  Do not “diet” – it’s doomed to failure.  Instead, find small changes you can make on a consistent basis that will decrease your calories by 250-500 calories a day.  For example, if you drink soft drinks (150 calories each), eat a bagel in the OR lounge  (300-400 calories), or eat at McDonalds on call (1000-1500 calories), change to diet sodas, cereal and bringing a sandwich from home.  If you think having the support of an on-line or real group would help, consider Weight Watchers or Spark People.

Exercise (almost) every day. Consistency is more important than quantity, so find something you like to do and “Just do it!”  It’s not easy to fit exercise into a busy schedule, but deciding to try is the first step!.  Another strategy is to increase your activity at work, especially on days you can’t actually work out.

Love what you do. You can decide to be a “romantic scholar”– to find enjoyment in difficult work and awe in learning.  It’s really easy to get caught up in how hard this work is and forget how amazing what we do is… and what a privilege it is to do it.  Make up your mind to cultivate a sense of awe about your work.  Keep a notebook, and write down what you learn from and about your patients.  Read more than you are asked to read, learn more than you are expected to learn – not to be a “gunner” but because you love medicine.

Nurture relationships with family and friends.  It’s easy to get caught up in the hours and hours we spend learning and practicing medicine.  Resolve to spend one night a week as a “date night” with your significant other, call close friends on a regular basis, keep in touch with relatives you don’t see very often.

Develop ways to deal with stress. Learn how to meditate and start a practice.  Spend time playing a musical instrument (or learning how to play).   Take yoga classes.  Join a church, synagogue or other religious community. Get a massage once a month.  Develop an exercise program which is one of the best ways to decrease stress (another reason to make this a New Year’s resolution!).

Tackle your debt.  Financial issues just add more stress to an already stressful time.  Assess where you are financially and develop a plan for dealing with the debt that all medical students and residents have to deal with.

If you need help with a personal issue, make an appointment. If you drink too much, use legal or illegal drugs inappropriately, suffer from depression, or have significant anxiety, please call and make an appointment with a health care professional.

Best wishes to all for a New Year filled with joy, health, success and happiness!

Thanksgiving Gratitude

Gratitude is not only the greatest of the virtues but the parent of all others.”  Cicero

Gratitude is a powerful tool.  There is good evidence that being grateful leads to a greater sense of well-being and less stress.   Practicing gratitude on a regular basis can be as simple as “counting your blessings” every morning, or listing things you are grateful for on your scut list, in a journal,or on your smart phone.  Another useful practice is to write letters (to send or not) to your parents, teachers, friends or mentors to thank them.  If you aren’t convinced that practicing gratitude can have a profound effect on your well-being,  take the “2 minute challenge”.  Get a piece of paper and for two minutes write down everything thing you are grateful for.  Don’t lift the pen off the paper and keep writing (non-stop) for the entire two minutes.

Today, as I am spending time with family and friends, making our Thanksgiving feast and counting our blessings, I am reminded that all over the United States, there are physicians, residents, nurses, therapists, and support personnel who are spending this holiday taking care of patients.  Along with the patients and families in their care, I am thankful for their sacrifice and their compassion.  It is a blessing to have the skills and the heart to care for others, and we are grateful for that privilege .

“If the only prayer you say in your whole life is “thank you,” that would suffice.  Meister Eckhart

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Elements of a Self-Care Protocol – from The Resilient Clinician by Robert J. Wicks

The following is taken from The Resilient Clinician by Robert J. Wicks.  Dr. Wicks writes primarily for psychiatrists and other mental health workers, but his advice is applicable to anyone who works with patients.

There are basic elements of a self-care protocol that most everyone needs to renew themselves on an ongoing basis. It really doesn’t  require too much to take a step back from our work routine to  become refreshed and regain perspective. Some of the basic elements  might include:

• Quiet walks by yourself

• Time and space for meditation

• Spiritual and recreational reading-including the diaries  and biographies of others whom you admire

• Some light exercise

• Opportunities to laugh offered by movies, cheerful  friends, etc.

• A hobby such as gardening

• Phone calls to family and friends who inspire and tease you

• Involvement in projects that renew

• Listening to music you enjoy (Wicks, 2003, p. 50)

Other simple steps at self-care and renewal might be:

• Visiting a park or hiking

• Having family or friends over for dinner or evening coffee

• Going to the library or a mega-bookstore to have coffee,  a scone, and to peruse the magazines

• Shopping for little things that would be fun to have but  not cost a lot

• Taking a bath rather than a quick shower

• Daydreaming

• Forming a “dining club” in which you go out once  a month for lunch with a friend or sibling

• E-mailing friends

• Listening to a mystery book on tape

• Reading poetry out loud

• Staying in bed later than usual on a day off

• Having a leisurely discussion with your spouse over  morning coffee in bed

• Watching an old movie

• Making love with your spouse

• Buying and reading a magazine you have never read before

• Fixing a small garden with bright, cheery flowers

• Telephoning someone you haven’t spoken to in ages

• Buying and playing a new CD by a singer or musician  you love

• Taking a short walk (without listening to music) before  and after work and/or during lunchtime

• Going to a diner and having a cup of tea and a piece  of pie

• Going on a weekend retreat at a local spirituality center or  a hotel on large grounds so you can take out time to walk,  reflect, eat when you want, read as long as you’d like, or  just renew yourself

• Arranging to spend a couple of days by yourself in your  own home without family or friends present just to  lounge around and be alone without a schedule  or the needs or agendas of others

• Getting a cheap copybook and journaling each day as  a way of unwinding

Starting Medical School: Rules of the Road

If you are reading this because you are preparing to start medical school – welcome!  You are now part of one of the most noble professions in the world.  You are no longer just a student, you are part of a profession… as of now.

Medical school is a wonderful, but at times difficult experience.  As you start this fantastic journey, there are a few “rules” I think might help:

1. You can drink from a fire hydrant, but you’ll need to learn how.

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  (more posts to follow with concrete tips on how to do this.)  But – here’s the good news.  You’ll be able to do it.   Everyone who has gone through this has thought at various times that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c)  there is absolutely no way to read all of this material.  And… we all discover that a) we are just as smart as everyone else (sometimes in different ways, but all effective) b) nobody made a mistake – we really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  Doctors are notorious for this; we forget that if we don’t take care of ourselves, we really can’t take care of others.   “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

3. Act like a doctor.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions in this context.  You’ll learn a lot of specific details about professional behavior as your apprenticeship goes on, like protecting patient confidentiality, peer review, etc.,  but the core values of professionalism start when you enter the profession, which is now.

4. Kindness matters.

It is remarkable how our paths in medicine cross over and over again.  The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now.  You and your classmates will be going through classes together (like you did in college), but this is different.  You are starting your professional life together as well.  The camaraderie that results is a gift and is also very important personally and professionally.  Don’t blow off the class events.  Don’t stay home to study instead of going to class.  Go out of your way to meet everyone in your class and really get to know them.  Cultivate and nurture these important friendships.

5. Enjoy the journey

The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  The basic science curriculum is not a rite of passage!   It turns out that even the “trivia” (or at least that’s what it will seem like) is important.  You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them.  Recording these moments doesn’t have to be by writing.  If you are an artist, you may want to use drawings.  Photos of your classmates (and some of those humorous moments) will become a treasure in the future as well.  (but remember the professionalism rule!)

Book Recomendation: Iron Doc by Mamta Gautam, MD

I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department).  Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness.  She uses training for an Ironman triathalon as an analogy.  Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout.  She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.

Here’s her website if you are interested:  http://www.drgautam.com/gautam/books.htm

Religion and Spirituality

People who are ill or hurting often turn to their religious roots for solace.  The mind and body connection is a powerful one, and one that can contribute to good patient care.  Spirituality in medicine can take an overtly religious tone, but only if both the physician and patient are completely comfortable.  No matter what your religious background, you will care for patients whose belief system is different from your own.  The true root of spirituality in medicine is compassion. Regardless of your religious background and your personal beliefs you can cultivate a philosophy of compassion.  Both you and the patients you care for will do better because of it.

 The workday can be onerous and fatigue can make you lose perspective.  It is important to find something greater than you and spend some time there everyday.  The most efficient method is to look inside of yourself by just sitting.  Learn to just sit.  It is harder than it sounds, but very powerful when achieved.  Slow your breathing, close your eyes and let the thoughts go.  Concentrate on your breathing and relax all your muscles.  Don’t fidget, don’t move.  When the thoughts start running (and they will), just acknowledge them and let them go.  Try to get to a moment (and that it all it will usually be) when your mind is silent and your body relaxed.  This is the moment to listen.  Being able to quiet yourself this way is very conducive to allowing your mind to work on the “big picture”.  If you spend even 10 minutes everyday in this kind of meditation, you will be surprised at how some of the things that are worrying you become “solved”.

 Work at finding beautiful places where you can sit for a minute or walk.  Nature is one of the most powerful spiritual experiences.  If you have a favorite place to hike or be outside, take some pictures and blow them up for your house or call room.  Put beautiful plants in your house and then take care of them. (Dead plants are a bad way to cultivate spirtituality…)  Watch for the surprising moments of beauty in a day and notice them.  Look for the flower blooming outside a patient’s room, the proud look of a father watching his two-year-old totter into the hospital, a new painting on the wall.

Cultivate a sense of wonder.  Have you ever seen anything more incredible than a beating heart in a surgeon’s hand?  Allow yourself a moment to be amazed in the middle of the day.  People have incredible resilience at times – notice it and appreciate it.

Life Math: An Essay by Marion Bishop, MD

This is a profound and wonderful essay about the “cost” of doing a residency. By comparing medical training to the life of Anne Bradsteet, a 17th century American poet, Dr. Marion Bishop discusses the sacrifices we make to practice medicine and how to consider them in the context of the gifts we receive as healers.  If you are discouraged about the years of training, the sleepless nights and the financial cost of medical training, please read this beautiful essay.

” …..    life is not a zero-sum game. A gain in one column does not necessitate a loss in another, and winning does not correlate with being debt-free or having the fewest losses in the final tally at the end of life. Rather, all losses are gains. All gains have corresponding losses. This is not harsh or bleak or cruel. This is being human. This is life. Sometimes you are talented enough to write it down.  And sometimes you are lucky enough to read what a wiser writer had to say about it 329 years ago.”

The link for this essay is no longer available to the public, but can be accessed through PubMed (JAMA 2007 Jul 18;298(3):266-8)