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?

Drawing credit

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.

Photo credit

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

The Best of Wellness Rounds 2011

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital

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!

Gifts for Medical Students and Residents

Gift ideas for college graduates who are getting ready to start medical school and medical students getting ready to start their residencies are surprisingly similar.  Medical school and residency are both times of hard work, less free time and increased stress.  The following are gifts that should make life a little easier (and more enjoyable) for medical students and residents:

  • A maid or housecleaning service once a week.  No one in medical school or residency has time to clean (or likes it)!  This will be one of the most appreciated gifts you’ve ever given someone.
  • Along the same lines, a highly functional laptop computer is a critical piece of equipment.  For new medical students, the laptop they had in college is probably not going to be enough.  For residents, if it has been several years since their last computer, an upgrade will make studying and research easier.  To avoid getting the wrong computer, a hand-made certificate that you will pay for the computer of their choice may be a better idea (to make sure they have a computer that really meets their needs.)
  • A year’s subscription to EverNote premium (to allow them to store notes on a cloud server)
  • If they are avid readers (of non-medical works), consider a Kindle, Nook, or other electronic reader.  (If you are considering an iPad, it can be used as a reader, so this might be redundant).  These devices can easily go into a backpack or call bag and make it easy to take 5-minute breaks from studying or work.
  • A really good alarm clock.
  • Membership to a gym for a year.  Working out is important both for physical and mental health during medical training.  But – unless you know which gym is the closest to where they live (or most used by their friends), it might be better to create a homemade “gift certificate” and let them decide.
  • Anything to help promote more exercise.  A bicycle to commute to school or the hospital?  A gift box with exercise equipment?  Yoga classes?
  • An iPod nano or other mp3 player to listen to music while studying   Electronic speakers for their computer will also help provide music while studying.
  • A subscription to Pandora One to create and listen to internet radio stations without commercials.
  • A gift certificate to Whole Foods (or any grocery store that makes take out food), or a healthy prepared food service.  In Houston, we have My Fit Foods, Snap Kitchen, Diet Gourmet, Real Meals 365 and several other services.  These types of businesses exist in almost every major city and can be easily found with an internet search.
  • If you are going to buy a watch to celebrate graduation, don’t make it an expensive watch.  No one wears them in the hospital for fear of losing them (they have to be removed when procedures are done).  It also is inappropriate when caring for patients who may not have many resources.  Ditto for expensive pens.
  • A digital camera or small digital video camera.
  • Anything to support a hobby that they enjoy (but will have to work to keep up during their training)
  • A couple of comments about what not to buy.  Don’t buy stethoscopes, otoscopes or any other medical equipment (unless you are a physician yourself… and even then it’s probably not a good idea).  Don’t buy anything for an office (they won’t have one for a long time) and – absolutely – don’t buy a “black bag” (no one uses them anymore).

How to Study During Your Residency

The study habits you set during your residency will be the foundation for the rest of your professional life.  Even though that sounds really melodramatic, it’s not.  If you don’t want to end up one of the “stupid” doctors, you’ll need to keep learning.  Medicine changes so dramatically that it is critical to stay on top of things.  Sounds easy, but it is amazing how few doctors develop a disciplined practice of being able to read and study.

Residency, despite what it may feel like some days, is the time that you are learning, and hopefully mastering, your specific profession.  All residents have an annual examination called the “in-service training exam”. It’s a nice marker of how you are doing when compared to the other residents in your field, and it’s motivation to stay on top of the didactic part of your education.   It is easy, like in medical school to try to “cram” for this test in a few weeks, but that’s really stupid.  The test is supposed to motivate you to learn, not to cram.  That being said, how you do on this exam is important, so you will want to review in the few weeks before the exam.  Your in-service score is predictive of how well you will do on your board exam and may be considered by programs if you end up applying to subspecialty fellowships.

So, what is the best way to learn your field and, as a secondary benefit, do well on the in-service exam?  How do you stay on top of the reading, and learn what you need to know?  Just like exercise, it’s far more important to be consistent than intense.  You can’t train for a marathon by running 15 miles once a month… and you can’t learn your field by “cramming” before the exams.  One way to do this is to set up a “training” program for your reading:

Buy the textbook in your field.  For many fields, there is more than one major textbook.  If that’s the case, ask around to see which one is considered the “best” (it will be subjective, but you have to start somewhere!).   If the textbook is on line at the medical school’s library you don’t have to actually buy the book, but you will miss out on the highlighting!  If there is more than one good textbook, plan to read a different one next year.

Map out the year into 46 week “blocks” (3 off for vacation, 1 off for the winter holidays and 4 off to review for the inservice exam).  Divide the textbook into 46 sections and assign the sections to the blocks.  Since I’m a surgeon, I’ll use an example from one of our major textbooks:

  • July 1:  Chapter 1 – Systemic response to injury and metabolic support and Chapter 35 – Soft tissue Sarcomas
  • July 8: Chapter 118 – Chest wall, lung, mediastinum and pleura
  • July 15: Chapter 6  – Trauma
  • Etc
  • Etc

Most textbooks front load with the basic science chapters (which are a little dry compared to the clinical chapters).  I don’t recommend you try to do the textbook in order or you will drown in the basic sciences (and forget why the field is fun!).

Make the textbook portable? If you are reading on line this may not apply.  If not, print out the chapter you are studying for the week from the online source or make a copy of the chapter from the book.  You may have to spend 5 or 10 minutes here or there getting through the chapter – being able to keep it folded up in your white coat pocket helps!

Read ahead and be flexible. If in the 2nd week of your study program you get a patient with breast cancer (for example), go ahead and read the chapter on breast.  It will be much more meaningful if you are applying it to a specific patient which means you are much more likely to learn the information.  Double up the chapters for that week if you can, swap if you can’t – but don’t lose track of the “training grid” (i.e. make sure you read enough to finish the textbook)

Use the SQ3R method when you are reading.  This is a great technique for actually learning what you read, rather than having it go in one ear and out the other (so to speak).

  • Survey – Look through the chapter at the section titles, graphs and tables.
  • Question – Go through a second time (again pretty superficially) but this time create questions that are likely to be answered in the chapter and write them down (this part is actually important, so take the time to write them down!).  For example, on a chapter about appendicitis, the questions would be something like:   What causes appendicitis?  What is the most accurate diagnostic test?  Is there an advantage to laparoscopic over open appendectomy? Etc etc
  • Read – Read with intention to answer the questions you generated and make notes for later review.  Take the time to actually write the answers to the questions you generated.
  • Review – Look over the notes you made and questions you answered.  Force yourself to list the key concepts to tease them out of the details.  Think about what questions you might ask on an exam on the topic.   Most importantly – you should review the material the next day (<5 minutes), a few days after that, and then a month later.  Set up a schedule and a method to make sure you keep track of this review.  Of all the steps that lead to really learning the material, this is probably the most important!
  • Recite – This is the one that seems stupid to most people, but it’s not.  Based on what is known about learning, reciting the things you really want to remember (out loud, not in your head) every time you review the material really helps with retention.  (Thank goodness for call rooms!)

Make notes so that you never have to go back to the book to review.   Use whatever system works best for you.  If you use the 3×5 card note system it will integrate with the other notes you are taking in the hospital.

There are other systems to make notes that work, too – so find the one that works best for you and then use it!  Some people type their final review notes in Word, Evernote or OneNote so they can search their notes.  Another unique way to make notes that are easier to remember is to use Mindmapping . Mindmeister and Xmind are on line for making these kind of notes, if this is what works best for you.

Organize your system for review. Your goal should be to read something every day and to complete the week’s reading every week.  In addition, you need to have a rotating system of review to make sure you look at your notes a day or two after you make them, a week later and a month later (at a minimum).  The more you review the more you retain, so build in as much review as you can.

Creating Your “Peripheral Brain”

My last post was about how to keep track of the information you are learning on different services.  http://wellnessrounds.org/learning-clinical-medicine-tips-for-the-hospital-and-clinic/

A related, but slightly different issue is the best way to create a “peripheral brain” for your clinical work.  Every medical student and resident creates their own “peripheral brain” to access reference material that they use on a regular basis.  In it’s simplest form, it can be a list of phone numbers for the rotation, faculty dictation numbers, etc.  In a more advanced form, it can include normograms for drug dosing, tables for probability of survival in the ICU,  lists of attending preferences for patient care, etc.

The internet has become a vast  “peripheral brain” for everyone in medicine.  We all use it to find information.   But it’s not ideal because it’s not specific for your needs.  For reference material you need over and over,  it’s more effecient to have it with you.   Unlike the system I described for studying (which is based on 3×5 cards), your peripheral brain should be digital.  My current recommendation for students and residents is to use Evernote.

In a nutshell, here’s how Evernote works:

1.  It’s free. (You can pay $5/month for the Premium version to have your data encrypted and to increase your storage, but you probably won’t need it)

2.  You create “notes” that are stored on a server by Evernote in your account.

3.  “Notes” on Evernote are more than just notes you type – they can also be photos you take, voice recordings, websites, clippings from websites or articles (tables, graphs, normograms, etc), pdfs, scanned images or text.. you get the idea.  Anything that can be stored digitally is a “note” in Evernote.

3.  You can access your notes on any computer, on your desktop (i.e. separate from the internet) and on your smart phone.

4.  You can search your notes.  This is by far the most amazing part of Evernote.  In essence it converts your notes to your own personal “Google”.  Evernote has text recognition for photos which really increases your ability to search.  For example, if you take a picture of a business card, you can search for it by any word that is on the card.

One big caveat.  Do NOT put any information about patients on Evernote.  Even if you pay for the encrypted version, it does not meet HIPPA requirements and you are breaking the law.

Here’s some links to more information about using Evernote:

http://academiclifeinem.blogspot.com/2010/02/evernote-redefining-my-organizational.html

http://computersoftware.suite101.com/article.cfm/why-evernote-is-made-for-medical-students

http://www.healthline.com/blogs/medical_devices/2008/09/evernote-for-doctors-revisited-privacy.html

http://efficientmd.blogspot.com/2008/08/how-doctors-can-use-evernote-as.html

http://www.screencast.com/users/rmacdona/folders/Default/media/63f89060-271d-405e-a544-d463ee267a2c

How to be the Best Intern in the Hospital

July 1st is almost here, and across the country newly minted doctors will be starting their internships.   The first night on call there won’t be an intern – anywhere in the country – who will sleep.  Every new intern is absolutely convinced that the beeper is going to go off and they won’t know what to do.  (You get over this by about the 2nd or 3rd call night, by the way).

Graduating from medical school and starting your internship is probably the most profound transition you will make in your professional life.  You have an MD after your name, and even though you initially feel like an imposter, you really are a doctor.  (Just to let you know – It takes about a month to stop looking behind you when the nurse turns to you and says “Doctor, what would you like to do?”)

Not too long ago a friend of mine (also an attending in surgery) shared his rules for residents:

  1. Write it down.
  2. Do it now.
  3. Call for help.
  4. Listen to me. (i.e. the attending)
  5. Don’t mess up.  (this is a slightly more polite version of the original rule.. )

If you follow these rules you’ll do fine.  But if you want to be known as the best intern in the house there are a few things you might not have thought about….

Be a doctor

  • Interns have a huge amount of scut work.  It’s easy to get lost in the trees and forget the “forest” – which is learning how to manage patients. It’s very easy to gather the data, write the notes and wait for the senior residents and attendings to develop the plan.  But that’s not the best way to learn.  If you want to do this right, force yourself to pretend that you are the only doctor seeing the patient…. What would you do next?  If you are ordering a drug, what are the side effects you might see?  If you are ordering a test, what do you expect it to show?  Take a minute to use UpToDate or PubMed to help you develop a plan.  When it turns out that the attending has a plan that’s different than what you thought you should do, figure out why!
  • At any given moment in time, be ready to present any patient in your care to your senior residents or attendings – all their history, all the pertinent physical findings, all the labs and imaging.   (Obviously, this means developing a system to have that data at your fingertips – more posts on that later) For critical data, try hard to be the first person to get the data and deliver it to the resident/attending.
  • Forget the hierarchy if something seems wrong.  Do what’s right.  If there is something in the “cockpit” that looks like it might lead to a crash – let everyone know.
  • Remember, you are taking care of people, not a scut list.   The classic example of completing the task (rather than caring for the patient) is writing all the discharge orders and notes, but not telling the patient they are going home.   Kindness matters.  Be the kind of doctor you would want taking care of you.

Show up (and be on time)

  • Be a real team member.  Every chance you get – look for ways to help your fellow residents.  Before you leave for the day, call the other interns and ask them if there is anything you can do to help them.  You want the reputation of “covering the back” of your fellow residents and doing more than is expected of you.  It’s the golden rule of residency – Help them the way you’d like to be helped.
  • Try to be the first one at work, and the last to leave (within the constraints of the rules!).
  • Be prompt for rounds (or any meeting with your senior residents or attendings).   If you are running late for a good reason, make sure you text or page the team to let them know why and when to expect you.

Teach the students.

  • You were just there! It’s about attitude, not time.  It only takes a moment to include the students in your work.  Explaining things you just learned to the students on your service will benefit you more than them (try it if you don’t believe me).

When (not if) you make a mistake, be totally honest.

  • You are not expected to be perfect – you are expected to care and to try your best.  Do not EVER lie – even about tiny, seemingly insignificant data.  If you don’t know the results of the test, say you don’t know (then run to look it up!).

Master your field.

  • If you are in a three year residency you have about 1000 days to become a master in your field… if you take away the days off, and the vacations, it drops to around 900.  If that doesn’t scare you – it should! Use it as motivation!
  • Read the most important textbook in your field cover to cover during your internship.  Develop a system for tracking what you have read so you can stay on schedule with your reading.
  • Make it a goal to learn 3 new things from every patient you see.  You’ll also need to develop a system that lets you find and review that information.  (more posts on that later)
  • Take personal responsibility for your learning.  Make a conscious decision that you will stay excited about learning – even when you are tired.

Smile.

 

  • Being an intern is stressful, but stay as upbeat as you can. Don’t participate in gossiping and complaining – it drags down the team.  If there is a problem to be addressed, define it and talk about solutions with your colleagues… but don’t just complain.
  • Take the time to step back and look at what you are doing from a bigger perspective.  It is incredibly cool… not to mention the fact that it’s meaningful work.   This is a tough year – no one will deny it – but it’s a very special year, too.  Keep some perspective on the big picture when you get tired.

An Open Letter to All Graduating Medical Students: Academic Medicine 84:539-540, 2009

This is a wonderful letter to all graduating medical students from Steven L. Kanter, MD, editor in chief of Academic Medicine.

“Remember that you take with you such an amazing gift to offer to society. Some of you will advance our understanding of medicine by discovering new knowledge, some of you will ensure our future by teaching others, and some of you will attend to the very meaning of life, one patient at a time.”

http://journals.lww.com/academicmedicine/Fulltext/2009/05000/An_Open_Letter_to_All_Graduating_Medical_Students.1.aspx

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Getting Ready for Your Internship

Everyone who has ever graduated from medical school worries that they aren’t ready.  If you aren’t a little worried, there is something wrong.  It’s a big transition!  But, that being said, I can reassure you that first, you are in good company; every new graduate feels the same way!  Second, your attendings and senior residents understand.  Not only did they feel the same way, but they’ve been through it a few times before with other interns.  They are there to teach you and help you learn your field.  It’s not always going to be easy, but you are never going to be completely alone as an intern – there will always be someone there to help.

Many of you will have the feeling that you need to review everything from medical school in the next 2 weeks, and read the entire textbook in your field after that.  STOP!  It won’t help and it will drive you crazy!  Here’s what I recommend instead:

1.  Develop a new exercise routine that you can stick with when you get really crunched for time.  Figure out something you can do for 20 minutes every day consistently.  After you move in to your new place (assuming you are moving to a new town), check out the gyms near work and/or your home.  Joining a gym should be a top priority.  But – you may want to wait until you’ve been at work for a few weeks.  There may be a preferred gym for most of the residents, and that’s the one you should join.

2.  Think about how you are going to eat well as an intern…. which is VERY hard.  Find the good grocery stores, prepared food places, take out (healthy) restaurants that are near where you work and/or live.  Read about nutrition, ask your family for favorite recipes.  Take a class or two to learn easy cooking techniques.

3.  Do spend a little time thinking about your new role.  You are going to have to master your field in a short time (it sounds long now… but just wait).  This is a good time to go through your medical school notes and take out the ones you know you’ll use during your internship.  Don’t read or study, just organize them so you can find them again when you need them.  If you know which textbook is the most recommended in your field, this is a good time to get it.  Don’t study … just skim through it.  You are NOT expected to know it yet, so don’t let this scare you.  Instead, take some time to marvel at all the amazing things you are going to learn, and the people you are going to be able to help with that knowledge and skill.

4.  Take a vacation.  I’m serious.  Spend most of this month visiting family, reading novels and hanging out on the beach.  Read poetry, call friends.  You’ve earned it!