Thursday, October 1, 2015

Be a Non-Terrible Intern in Ten Easy Steps

Image Credit: ReSurge International
Author: Gregory Wanner, DO PA-C
Thomas Jefferson University Hospital

Welcome to residency! Now that you’ve had some time to learn the hospital computer system, find the coffee maker, and begin to settle into your new role as an intern, it’s time for a few tips. Intern year is tough. You have a whole new set of responsibilities, and for some this is your first “real” job. There are many ways to be a terrible intern, but you can avoid terribleness and become a wonderful intern.

Over my ten years in medicine, initially as a physician assistant and now as a senior resident, I’ve had quite a bit of exposure to interns. Plus, I was one not so long ago. As interns we all have times — often brief — when we feel brilliant, as well as times we feel completely incompetent. We have moments of enlightenment and moments when we need to be bailed out by nurses or attendings. This is to be expected. The goal is to learn from your mistakes and eventually become a great physician. To learn what you can do to further your own education, keep your attendings relatively happy, and avoid terribleness: read on.

In order to figure out what differentiates the wonderful interns from the terrible ones and develop some recommendations, I surveyed 18 attendings with a combined total of 156 years of experience working with interns. I used their responses and my own experience to develop the following ten steps to being a great intern.

Early habits. 
Develop good habits early. Don’t cut corners. Get in the habit of eliciting a full history, documenting thoroughly, and giving complete sign-outs. When appropriate, do a complete physical exam and undress your patients. It’s amazing what you’ll find, whether it’s an infected wound, a penetrating injury, or an entertainingly dirty tattoo. Learn to do things correctly now, even if it takes a little extra time.

Be a bit nervous. 
Overconfident interns hurt people. Don’t hurt people. That’s bad. You’re not a medical student anymore and your orders actually matter. Be nervous about that. Ask questions. Look up medication doses, interactions, and basic mechanisms of action when ordering a drug. Don’t rely on the nurses or the pharmacist to catch mistakes. Although they often do, you are still responsible for what you order.

Request it and accept it graciously, rather than getting angry or defensive. Nearly all of the surveyed attendings rated “willingness and receptivity to learning” as the most important quality of an intern and a “know-it-all attitude” as one of the most dangerous qualities. Proclaiming “I’m the doctor!” or “In my experience…” will get you nothing but laughter and eye-rolls. Some interns have egos larger than their experience levels. Do you? Ask for feedback about how you’re doing and make changes
based on what you hear.

Assessment and plan. 
You aren’t in med school anymore. Now you get to make a real plan — with attending input, of course — for your patients. Adjust your differential diagnosis list as you evaluate and examine your patients. Think about which tests you want to order and why you want them. Have a plan in mind when you present to your attending or senior resident. Most attendings rated “accurate history and physical exam skills” as a very important intern quality, even above “formulating an appropriate treatment plan.”

Shut up, listen, and be humble. 
That may sound harsh, but whether you’re dealing with patients, nurses, or attendings this is a good recommendation. Keep quiet for a minute or two while your patient talks; interesting things will come out. Be nice and listen to your nurses; their input will save your gluteus if you let it. Learn from your attendings. Their knowledge and experience will help you develop your own practice style.

This is your way of telling the story after the patient encounter is over, and both your future earnings and the outcome of the inevitable lawsuits will depend on the quality of your documentation. Be honest and document well. Paint the picture you want others to see. Both your colleagues and attorneys actually look at your charts. Correct spelling mistakes, review nursing notes, and tie up loose ends that are apparent in the chart.

Learning now, speed later. 
Your efficiency and speed will be important in the future, but not yet. All surveyed attendings agreed that “learning emergency medicine content” should be a main focus this year, while only 17% of attendings felt “efficiency” should be a main focus. Overall, attendings felt interns should see an average of one patient per hour. See patients, learn from them, and gradually increase your speed throughout residency.

Off-service rotations. 
Work hard and you’ll gain respect from other services. They don’t expect you to know everything about their specialty; that’s why you’re in residency. It’s ok not to understand surgical concepts on your trauma surgery rotation, or how to measure a cervix on OB. You may even ask a stupid question or two. That’s okay. Work hard and try hard, and they’ll appreciate it. It will help when you’re calling consultants later.

Lateness and call-outs. 
The best way to anger your colleagues is to be late or to call-out sick for nausea or rhinorrhea. This is emergency medicine — we have IVs and anti-emetics — we can treat you. Show up to work or else you’ll look like an anus, and we have a scope for that.

Your most important teacher is you.
From reading on your own to being proactive with seeing patients and getting procedures, you are your own best teacher. From now until the end of your career, most of your learning will be self-directed. After your shifts, read about a few of your patients’ conditions. This will help link clinical experience and textbook knowledge in your mind. Take advantage of clinical simulations and consider using online content such as FOAMed, but don’t abandon journals and books.

Congratulations, you are now armed with the tools for success during the rest of your intern year. Use these tools wisely. Stay humble, be nice, ask questions, welcome feedback — and you’ll find yourself on the path to a successful trip through residency.

This article is featured in both Common Sense and the AAEM/RSA blog. We invite attendings, fellows, and senior residents to add their own recommendations for interns to the comments section of the blog.

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