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.



  • 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.”

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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!

Top Gifts for Medical School Graduates

This may be open for (a lot of) discussion… but here’s my list.  Feel free to send it to parents, significant others, etc.  If anyone has any other ideas, let me know – I’ll keep adding to the list!

1.  A weekly maid service for period of time (a year if you can)

2.  A gym membership for a period of time (a year if you can).  Probably better to make this a certificate of some kind for “after you get settled” – if they are moving to another city for their internship, they will want to join the gym that their friends use.

2.  A new (top of the line) smart phone

3.  A Kindle or other electronic reader (plus a gift certificate for non-medical books, if you can)

4.  “Homemade” meals certificates (if you don’t live somewhere close and can’t do this yourself, find a “ready prepared” food service.   I googled for “premade healthy meals” in Houston, for example,  and found at least 8 different businesses that do this. )

5.  Gift certificates to Whole Foods market or other healthy grocery stores.

6.  A new laptop with video (if they don’t have one that lets them use Skype or other video services)

7.  A week of vacation before they start their internship.

8.  A nice pen will be appreciated… and might be used… if it’s not immediately lost when you are on call…

9.  If you are thinking about a watch (which is nice) remember where it is going to live and that it will be taken on and off all day.  It should have practical things like an alarm and a stopwatch/second hand.  It’s fine to get a fancy watch, but it will be worn on vacation or trips home (and not in the hospital).

10.  A letter with all the things you think are wonderful about them, why you are proud of them and why you think they are going to be a fabulous doctor.

11.  A wok.  It turns out that cheaper (carbon steel) is better than expensive when it comes to woks.  Do a little research on the subject, but I recommend the classic, round bottom cheap wok.

12.  Kitchen supplies to cook for themselves.  There are several options in this category:  a good set of knives, a set of pots and pans, baking supplies, or a gift certificate to a cooking store.

13.  A gift certificate to Penzey’s spices ( if they are already a cook (or you think it will encourage them to cook)

What NOT to buy —-

1.  Any medical equipment (unless you are a practicing physician yourself and it’s specific to the graduate’s chosen specialty).

2.  A black bag.  This is a little debatable because these are very sentimental… but no one I know has ever used their black bag.

3.  Anything for an office (won’t happen until after residency, so save this for when they finish their residency)

Preventing Weight Gain in Residency

This is the time of year when 4th year medical students are winding down and preparing for the “big move” into internship.  Our 4th year students take a special 3 week course to get them ready – a wonderful mix of small groups on professionalism, ACLS training, first night on call beeper emergencies…etc, etc.  It ends with a small group of senior faculty who talk about making the transition to residency.  I wish we’d recorded the talks – they were all really wonderful.  In addition to giving wonderful professional advice,  all of the faculty included advice on taking care of yourself.  It struck me that one of the specific issues that each of them mentioned (well, four out of five) was how much weight they had gained in their internship and residency.

Losing weight is not easy for those that struggle with this issue – but preventing weight gain is not as hard – and should be a goal for every intern and resident!   It’s not hard – you need to increase your activity (a little) and watch out for stupid food choices.   Here’s the “rules” I wish someone had given me before I started my residency (if you have rules you would add, please send a comment!)

1.  No junk food (doughnuts, pizza, hamburgers, etc)

2.  Take healthy food with you to work – especially for call nights.  Keep emergency healthy food in your locker i.e. high quality energy bars, dried fruit/nuts (in appropriate small portions).

3.  Make sure you get an hour of real exercise on days when you are not in the hospital

4.  Take the stairs instead of the elevators.

JAMA. 2010 Mar 24;303(12):1173-9.

Physical activity and weight gain prevention.

Lee IM, Djoussé L, Sesso HD, Wang L, Buring JE.

Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA.

CONTEXT: The amount of physical activity needed to prevent long-term weight gain is unclear. In 2008, federal guidelines recommended at least 150 minutes per week (7.5 metabolic equivalent [MET] hours per week) of moderate-intensity activity for “substantial health benefits.”

OBJECTIVE: To examine the association of different amounts of physical activity with long-term weight changes among women consuming a usual diet.

DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study involving 34,079 healthy US women (mean age, 54.2 years) from 1992-2007. At baseline and months 36, 72, 96, 120, 144, and 156, women reported their physical activity and body weight. Women were classified as expending less than 7.5, 7.5 to less than 21, and 21 or more MET hours per week of activity at each time. Repeated-measures regression prospectively examined physical activity and weight change over intervals averaging 3 years.

MAIN OUTCOME MEASURE: Change in weight.

RESULTS: Women gained a mean of 2.6 kg throughout the study. A multivariate analysis comparing women expending 21 or more MET hours per week with those expending from 7.5 to less than 21 MET hours per week showed that the latter group gained a mean (SD) 0.11 kg (0.04 kg; P = .003) over a mean interval of 3 years, and those expending less than 7.5 MET hours per week gained 0.12 kg (0.04; P = .002). There was a significant interaction with body mass index (BMI), such that there was an inverse dose-response relation between activity levels and weight gain among women with a BMI of less than 25 (P for trend < .001) but no relation among women with a BMI from 25 to 29.9 (P for trend = .56) or with a BMI of 30.0 or higher (P for trend = .50). A total of 4540 women (13.3%) with a BMI lower than 25 at study start successfully maintained their weight by gaining less than 2.3 kg throughout. Their mean activity level over the study was 21.5 MET hours per week (approximately 60 minutes a day of moderate-intensity activity).

CONCLUSIONS: Among women consuming a usual diet, physical activity was associated with less weight gain only among women whose BMI was lower than 25. Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately 60 minutes a day of moderate-intensity activity throughout the study.

PMID: 20332403 [PubMed – indexed for MEDLINE]