Welcome new PG-1’s! One day you wake up a medical student. Then by the afternoon you are a MD. A few short days later, you are now in the hospital no longer looking for someone to co-sign your orders in the EMR.
It’s a crazy time, full of excitement as well as an inordinate amount of stress.
My list is not for your first day of the first week. But maybe bookmark it for after you get your sea legs under you. After you know where to park the car and where to get that much needed cup of coffee. This is for after you figured out how to login to the EMR and PACs system and know the pattern (or lack thereof) to your days on your first rotation. Then, come back here and re-read. When you have the bandwidth to actually process. There are many pearls out there for new interns. There are handbooks, pocket guides along with Twitter full of words of wisdom. The five I have written about here I think will serve you well as interns and beyond.
- Don’t forget the chief complaint.
My closest calls and near misses over the years have been when I neglected to pay adequate attention to the patient’s chief complaint. They may be in florid heart failure with a pulse ox of 70% and not making any urine. But all they care about is the pain in their calf. While I am placing them on non-invasive positive pressure ventilation, nitro drip and Lasix, two hours later I find them in the OR for compartment syndrome. Their chief complaint may not be at the top of YOUR problem list, but it is at the top of THEIRS. It may not always end up being a life or limb threatening process, but then again, how do you know if you don’t check it out. Always respect the patient’s chief complaint. If you do not bother to pay attention and address it, what else is your patient telling you that you are not hearing!
2. Ask that question!
If you are uncomfortable asking as an intern, how will you do it when you are an attending? I will let you in on a little secret. We (the attending’s) do not know what’s going on all the time. But I do know where to go to get help. What resources I have in the form of other colleagues, partners, consultants, etc. You are not expected to know everything. Definitely not as an intern. But we doctors can be an interesting bunch. We often feel like imposters, especially early in our training. That we do not belong. Yet we have pride and ego that compete with our feelings of insecurity. This is an awful construct to have in your head. Break it. Ask the question. I am willing to bet someone else on rounds has the same one. By asking, you encourage the next person to speak up. By sharing what you do not know, you foster an environment that encourages learning and is better for patient care. More importantly, you will recognize that this doesn’t stop after intern year. Welcome to being a life-long learner
3. Approach with caution the patient with psychiatric illness.
It’s hard when the patient’s history of mental illness gets put up front during sign-out from the ED or on your chart review. Our biases often kick in whether we intend to or not. Often the patients ability to give a good history and report symptoms accurately gets called into question and their voice gets tuned out in the shadow of their mental illness. Patients with mental health issues can just as easily develop physical illness. Which often in turn leads to exacerbation or decompensation of their underlying psychiatric diagnosis. Too often we dismiss out of hand their complaints or the “pan positive review of systems”. It is hard when someone’s psychosis or mania or anxiety is raging to discern what is the truth. But be disciplined and approach all patients with same level of concern. Don’t stop listening and tune the patient out. That abdominal pain, even though it is the 5th time they have been to the ED, can still be an appendicitis.
4. Don’t fear the family.
I remember dreading walking into rooms with family members. They were more able in body and mind to ask questions and were not so easily dissuaded by my quick in and out of the rooms trying to get thru my morning pre-rounds. I feared them. Not just because of the time they took that I did not have, but also, I felt they would expose me for what I was. An imposter. Unable to answer their questions, I feared more what they made me think and feel about myself.
They fear too. They worry about their loved ones. They are confused, out of place, disoriented and are trying to advocate in the best way they know how. Don’t fear them. Lean into them. Sit down. Answer questions even if it means saying you do not know. Start getting comfortable with diagnostic uncertainty and being able to talk about that with patients and families. Honesty combined with empathy goes a long way towards building trust and confidence.
5. Recognize wins.
I have written about this before in another post 10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit but I think its important enough to include here as well. Learn to retrain your brain. As physicians, we tend to focus and dwell on what went wrong. The challenging patients and families. Frustration over missing labs or delays in imaging. The complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of medical illness. Treating a “routine” COPD exacerbation and managing them through their hospital stay to discharge without any drama or significant adverse event is no easy task. But we fail to value our role in this as a win. It is viewed as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. We focus so much on what goes wrong or in our perceived failures to help or heal our patients we end up ignoring all the positive around us.
Best to all the new interns on the start of a new journey. Exciting times lie just ahead. If you enjoyed this post and want to hear more thoughts on medicine and work-life balance, please sign up to follow this blog!