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!

Cold Summer Treats

It’s summer and it’s hot.  I’m on call this weekend.  That combination made me think about cold comfort food I could take to work.

Chocolate (in any form) is always the answer… but I decided maybe I could find something a little more healthy (and a little less caloric) that could serve as the “treat” we all crave when we are working hard on call.  I’m thinking the team will like a little Salpicon mid afternoon tomorrow…

Salpicon – a sparkling fruit drink from Columbia

This soup looks delicious, but with the heavy cream probably isn’t in the “low calorie” list.  You can substitute milk or yogurt to cut calories (without too much sacrifice of taste).  But, then again, as an on-call treat this still beats McDonald’s!  This is just one example of cold soups – which are great for summer on-call days.

Cold avocado soup

Smoothies are great comfort food – but logistically not easy when you are on call.  If you love smoothies, you might want to invest in an inexpensive single-serve blender.  Take the fruit in a baggie, put some yogurt and ice cubes in… instant smoothie.  Alternatively, you can blend your smoothie at home and put it in a container in the refrigerator that you can shake up before drinking.

Banana mango smoothie

Fast Easy Recipes: Skinnytaste.com

In keeping with this month’s goal of cooking more at home, I thought I’d share a website with you. Skinnytaste.com has great low fat, low calorie recipes that are easy to cook (and family tested).  Even if you are not worried about your weight, these recipes are great for being on call – lots of energy and lots of food without too much fat (which will make you sleepy).

Recipe for cheesy zucchini enchiladas

low-carb-zucchini-enchiladas

Recipe for Shephard’s Pie (LIghtened up)

shepards-pie3

Recipe for Southwestern Black Bean Salad

Healthy Habit: Get Moving!

One of my New Year’s resolutions was to come up with monthly “resolutions” for myself and for anyone who follows this blog.  Cooking Light magazine (which is one of my favorite sources of recipes and ideas for healthy living) had the same idea, so I am shamelessly borrowing their healthy habits!

Cooking Light’s 12 Healthy Habits

It’s a lot easier to commit to 30 days of a new habit than a full year.  So this month’s goal is to maintain or improve fitness by increasing activity.

It may seem daunting to stay in shape or even improve your fitness level when you are swamped with studying or work in the hospital.  It’s not easy, but it is absolutely doable.  The best way to start is to pick one or two of the following ideas and make them a resolution for this month.  Pick goals that are “SMART” (Specific, Measurable, Attainable, Realistic and Timely) and then just do it! Consistency is the most important part of setting this goal – so pick something that you know you can do on a regular basis.

Some ideas to consider:

  • Take the stairs at work instead of the elevator
  • Commute to school or the hospital on your feet or on a bicycle
  • Park as far away from school or work as is reasonable and walk the rest of the way
  • Plan ahead for 10 minutes of exercise while you are on call and take what you need
  • Wear a pedometer and get 10,000 steps/day
  • Do push-ups every morning before you go to work
  • Find a cardio exercise that isn’t boring for you and do it 30 minutes 3x/week
  • Run.  It’s easy, it’s cheap and it’s the most effective exercise for busy people!
  • Hire a trainer for one workout a week (or ask for this as a present)
  • Play golf, tennis, racquetball – any game that gets you moving!
  • Find a spin class or other organized exercise class to attend once a week
  • Organize a basketball or ultimate Frisbee game with your friends once a week
  • Shoot for a total minute goal/week of exercise (start with 100?) and keep track
  • Whatever you decide to do, PLAN – make it an appointment on your calendar, put it on your daily scut list, get your clothes out the night before – do whatever it takes to make it happen!

Easy Ways to Increase Activity at Work

The Institute of Medicine recommends 60 minutes of vigorous exercise everyday to maintain optimal health. The scientific evidence is clear – we would all be healthier if we did real exercise for an hour a day.  But – as Dr. Richard Forgos says in his commentary on the subject  – “An hour a day? You’ve got to be kidding!”  I agree – It’s next to impossible for most physicians, students and residents to find an hour to exercise every day.  (Which is really more like 1½ or 2 hours if you plan to go somewhere like a gym).

That being said, any amount of exercise you can add to what you are (or aren’t) doing now will improve your health, help you control your weight, and improve your mood.  When you can, try to schedule a real workout.  When you can’t, focus on easy ways to add small amounts of activity into your normal day:

Take the stairs.  For one week, make yourself take the stairs every time you change floors.  You’ll see an improvement in your huffing and puffing by the end of the week, and you’ll be convinced that this is real exercise!  When I was a resident, one of our legendary attendings climbed a new mountain every summer during his vacation.  The only training he ever did was to take the stairs in the hospital.  (He looked great after 10 flights of stairs… the interns were suffering.)  At a minimum make a 2 or 3 floor rule i.e. take the stairs if you are going up 2 or 3 floors.  You should always take the stairs if you are going down!

Commute on your feet. If you live close enough (and it’s safe), walk or bike to work.  If you have to drive, park farther away than you usually do so you have to walk a little farther.

Wear a pedometer. Find out how many steps is an “average” day for you and set a new goal.  Shoot for a minimum of 10,000 steps a day.

Don’t stroll on rounds.  A lot of people who give advice about increasing activity talk about “walk meetings”.  We have walk meetings all the time!  (We call them rounds.)  If you are in charge of rounds, set the standard by walking quickly between areas and taking the stairs.

Drink a lot of water and then use restrooms on a different floor. No one drinks enough water at work, so this helps meet that need.  The obvious consequence of drinking enough water can lead to more walking!

Stand when you are talking on the telephone or writing in a chart. This sounds trivial, but it actually adds a lot to overall activity.  If you are somewhere you won’t be embarrassed, add some squats or lunges while you are talking.

Have active post-call “team meetings”. Instead of meeting for a “beverage” at a restaurant (or other establishment), go play Frisbee in the park (beverages allowed).  (Picture from http://en.wikipedia.org/wiki/Flying_disc)

10 simple ways to increase your physical activity – obesitypanacea.com

Increasing daily activity – American Heart Association

Exercise at work – about.com

How Many Push-Ups Can You Do?

It may seem weird to do an entire post on push-ups…. but push-ups are an incredible exercise and not very time consuming.

New York Times article about push-ups

In the busy life of students, residents, and practicing docs it’s easy to lose track of your own fitness.   There’s no question that consistency, not quantity is the key to success in staying fit while you are busy.  Which means you have to give up the notion of working out for any specific time period and realize that even 10 minutes a day matters.

Which is where I got the idea for push-ups.   (Well, to be honest, I started thinking about push-ups when I heard about one of our residents who recently ended up in a tie-break challenge in a trivia contest.  The tie-break was to see how many push-ups you could do.  She beat two big guys…. in high heels and a strapless dress!)

For the fledgling anatomists (since a lot of first year students are studying upper body anatomy right now):  The primary muscles you use in doing a push-up are the pectoralis major and minor muscles.  The key secondary muscles are the triceps and anterior deltoids.  But – because a push-up is basically a plank with motion, you also use muscles in your abdomen, back, and legs, too.  This is why it’s such a fabulous exercise to maintain (and even build) fitness if you don’t have much time.

The form you use in doing a push-up is important.  Cheating not only diminishes the return on your exercise investment, it can actually hurt your back.   Here’s two websites that explain the details on proper form for a push-up:

How to do a proper push-up

How to do a push-up

Most women, and some men,  won’t have enough strength to start with “regular” push-ups.  The form is really important – if you can’t maintain your back straight during the push up, or get your body down all the way to the floor, you’ll need to start with a modified push-up.  Don’t worry, it won’t take long and you’ll be able to do the “regular” push-up.  Don’t risk hurting your back (even if you are feeding your ego) – start where it’s appropriate!   If you haven’t done push-ups before, you’ll probably need to start with knee push-ups and then move on to “hand elevated” push-ups.  Push-ups are easier to do if your hands are higher than your feet, like against a wall or hands on a table or chair.  An easy way to use hand elevated push-ups to train for “regular” push-ups is to use steps (like the stairs at work when you are on call or at school if you are in the basic sciences).   Start with your hands on the 4th or 5th step in front of you and do your set of push-ups. As you get stronger, move one step down.  Eventually, you’ll move down through all the steps until your hands are on the floor.

Training to do pushups isn’t hard, and, with a little planning and coaching, you’ll be able to do many more than you think.  Here’s the url for a great website that explains how anyone can get to the point that they can do 100 pushups:  http://hundredpushups.com/

Just for fun… the world record for consecutive pushups is 10,507, set in 1980 by Minoru Yoshida.

You are probably pushing the equvalent of about 50% of your body weight when you do a push-up.      http://www.funtrivia.com/askft/Question23103.html

Push-ups are called press-ups in the UK  http://en.wikipedia.org/wiki/Press-up

Tour de France Rice Cakes

I’m addicted to watching the Tour de France.  It’s an amazing athletic event, and the images (at least on HD) are simple astonishing.

There was a really great “side story” on tonight’s Tour broadcast about Dr. Allen Lim, a PhD sports physiologist.  The segment was specifically about his rice cakes – a real food equivalent of a commercial energy bar used by the Radio Shack riders.   http://dailyburn.com/recipes/dr_allen_lim_rice_cakes.

IMG_1510

I haven’t made these yet, but I’m pretty certain they are going to be really good and – more importantly – a great call/energy food for busy students and residents.  He has some other recipes that would probably be good on call energy food, too

Here’s a video on how to make these rice cakes.   http://www.cycle-ops.com/videos.html?id=50

Photo from http://bikefleet.blogspot.com/2009/03/allen-lims-rice-cakes.html

Salads

For medical students in basic sciences, a salad can be a great “energy” lunch that lets you stay alert in class.  For students on rotations and residents, a fresh salad is a great lunch and an even better middle of the night meal when you are on call.

The concept couldn’t be easier – put lettuce, spinach, or the greens of your choice in a big container.  Top with protein, cheese, veggies, nuts and/or fruit.  If you don’t care what it looks like, it’s also really easy to dump it all in a big zip-lock bag.  When it’s time to eat, pour the salad dressing in the bag with the salad, shake, and then serve yourself from the bag.

Protein:  Beans from a can, beans you make yourself with a crockpot or pressure cooker (which saves money and avoid excess salt and additives), canned tuna, cooked chicken from the deli, prepackaged meats (look at the labels to make sure you aren’t getting a lot of additives you don’t want), shrimp, etc.

Cheese:  Shredded cheddar, Monterey jack or Mexican cheese (reduced fat or regular), feta, goat cheese, thin slices of parmesan

Veggies:  Any leftover in your refrigerator!  Another good idea for this is to buy what you need for a mirepoix when you do your once a week shopping.  A mirepoix is the basis of  French cooking and is one part onions, one part carrots, and one part celery.  The Cajun trinity is similar but substitutes green bell pepper for the carrots.  If you buy the ingredients for a mirepox (or trinity) and chop it up on the weekend, you can use handfuls in salads, omelets, soups, etc all week.  (You can add other things, too, like mushrooms, red bell pepper, etc – anything that can be eaten raw).  If its a really busy week and you don’t have time to chop up vegetables, you can used canned green beans, corn, beets… whatever vegetables you like.

Nuts and/or fruits: Adding some dried fruits and nuts, sunflower seeds, etc, will add some extra nutrition.  Fresh fruits like blueberries, strawberries, sliced peaches are delicious in salads.  Canned fruits, especially mandarin oranges, are good, too.

Salad dressing. Don’t put the dressing on the salad until you are ready to eat.  (The French say it “cooks” the salad… but the result in any language is soggy salad.) My favorite dressing is a homemade vinaigrette.  Start with vinegar (red wine, white wine, sherry or balsalmic), a clove of diced (not crushed) garlic, a healthy teaspoon of good Dijon style mustard, salt and pepper.  Stir these all together until the salt is dissolved and the mustard is blended with the vinegar.  Add olive oil while you are stirring (or shake it up at the end.)  The classic ratio is 1 part vinegar to 2 parts oil, but you can add less oil to taste.  I usually squeeze a little lemon juice in, too.

The easiest thing by far is bottled salad dressings.  Be careful about calories (if you are watching your weight).  If you take salads to work regularly, you may want to leave the bottle there (unless the food snatchers raid your refrigerator on a regular basis).

http://allrecipes.com/Recipes/Salad/Green-Salads/Top.aspx

http://hubpages.com/hub/Favorite-Salad-Toppings-Lessons-From-Restaurant-Salad-Bars

http://www.fitsugar.com/Nutritional-Information-Salad-Toppings-7598444

Healthy Sandwiches

Making a healthy sandwich for lunch is a great way to insure that you don’t eat the leftover pizza from last night’s call team.  A really good sandwich which balances protein and carbs is also a great way to get through a long call night.  Keeping your energy up when you are up all night on call is difficult but there are tricks to maintain energy for call. The most important way to have good energy on call is to eat good quality food every 3-4 hours. Sandwiches are great for call because they are so easy to make, easy to store and easy to put in a pocket to eat on the go.

Pick good ingredients whenever you can.  It’s worth paying a little more to have food that is just food (and not a lot of fillers, corn syrup, transfats, etc).  Make sure you get high quality bread – 100% whole wheat is best, but if you really don’t like whole wheat, at least try to get as much whole grain in the bread as you can. Whenever possible, add veggies to add nutritional value.

Peanut butter sandwiches have the advantage of not needing refrigeration.  You can keep them in your white coat pocket if you want to (an advantage on a busy day).  You can stay traditional (i.e. peanut butter and jelly), or up the nutritional content by adding banana (or other fruit) or with other unusual combinations.

Egg salad sandwiches are great in the middle of the night when you are on call.  101cookbooks.com egg salad recipe is a pretty classic recipe which is really wonderful.  If you want to up the protein and decrease the fat leave out some or al of the egg yolks and use lowfat mayonnaise.  There are other options for traditional egg salad recipes, too

Tuna or chicken salad sandwiches can be made with classic recipes, or less traditional ingredients that up the nutritional content such as spicy tuna salad, or other unique tuna salad recipes.

Lean meat (chicken, ham, pork, beef) makes a great, high protein sandwich.  Add cheese, tomatoes, spinach, shredded carrots or other veggies to increase the nutritional value.  If you are watching your weight use low-fat cheese and avoid mayonnaise.  If you use hummus or avocado instead of mayonnaise or other spreads you’ll also make the sandwich more nutritious.

Here are a few other sites to help you be creative with your sandwich ideas:

Healthy Sandwich Recipes & Tips

Love Your Lunch: 10 Healthy Sandwich Recipes

Good Nutrition is in the Bag: Healthy Sandwich Alternatives

How to Eat Well On Call

It’s Saturday and I’m on call – and it’s going to be a busy day!  We have about 75 patients on the service, we already have 4 cases done and another 4 posted, and it’s still early (~4pm)   I have a fantastic resident with me today.  We just were chatting about what we are going to do for meals today.  He didn’t have breakfast and has only had a Coke and a “borrowed” bowel of Kix cereal from the recovery room so far.  I had whole wheat toast with some goat cheese before I left my house this morning, and I here’s what I have to eat today:

  • Strawberries
  • A handful of frozen cooked shrimp with cocktail sauce (they’ll thaw by the time I want to eat them)
  • Frozen peas (I put them in the microwave for a minute but, like the shrimp, frozen would be fine because they’ll thaw) + goat cheese, olive oil, vinegar, salt and pepper
  • Leftover whole wheat orzo, artichoke hearts, tuna and lemon pasta from last night
  • An apple
  • Lemon wedges for water

My resident’s Coke is probably more than I used to have as an intern… which is STUPID.   Eating well is important to feel well, perform well and do the right thing for your patients. There is one word that explains the difference between my resident (and what I used to do) and what I do now… planning.   “I’ll just get something from the restaurant across the street later…”, “There will probably be food leftover from the GI conference…” .. “I can always eat a bagel from the lounge..” … NOT.   When you finally have a minute to grab something to eat, you won’t usually have time to go look for the food.  It’s a lot easier if its’ there and ready to eat.

Here’s how to do this right:

1. Buy a good “lunch box” .

I like the hard plastic ones that fit in an outside, insulated carrying case.  It’s a lot easier to clean up if something spills than the usual “lunch box”.

You can use plastic (disposable) containers to carry your meals with you.  I’ve switched to glass containers because some of the data about heating the plastic containers in the microwave started sounding convincing.  It does mean you have to keep track of them and bring them home, but I suspect in the long run (if I don’t lose them) it will be cheaper than the plastic containers.   I particularly like the ones I bought because the seal is so tight that they don’t ever leak  (even for things like soup).

2. PLAN.

The night before call, figure out what you are going to take. Make it good stuff, too!  Call nights are not the “what I know I should eat” nights.  You need to have real food (i.e. not processed) but don’t skimp.  When you get to the “I really deserve those french fries” time of your call (which we all do) you will have really delicious and balanced food  in the refrigerator.

3. Pack your meals for the next day the night before (no matter how late it is or how tired you are).

It’s the only way you’ll actually do this.   None of us when we work this hard have the energy to put together meals for the day at 5am.  This takes a little effort but the payoff is real.  You will absolutely eat better, have more energy, maintain your weight and do a better job.  Don’t forget to throw some fruit in – and to make sure it’s washed so you can just pull it out of the refrigerator for a snack.