Advice to new interns from a nurse turned medical student

If you’re a new intern you are hopefully a little afraid of the new found responsibility in your life. I say “hopefully” because there is nothing more frightening in healthcare than someone who is “unconsciously incompetent.” That is, someone that doesn’t even realizethey have no idea what they are doing.

Before starting medical school I was an emergency nurse. As an RN, I had the opportunity to see many medical students, interns, and residents flit in and out of the department, and I noted some of the the strategies that differed between the ones that shone and the ones that sank. To give some insight into how to be in the former category I’ll pass on some pointers from my former vantage point, to those of you who’ve recently landed feet-first in the hospital.

You are book rich, experience poor.You may know all the cytokines involved in septic shock, but the RN knows what it looks like from 30 ft. Guess which of the two abilities is going to save your patient’s life? You’ll get there too, but in the mean time, pay attention to the patients that the RN’s are concerned about. Which brings me to my next point.

Spidey sense. Cannot be learned, it is developed through experience. Many nurses have been in health care since you were wearing short pants and they’ve got pattern recognition down to a science (or some might say, a freakishly intuitive level). Good nurses know the “sick look,” so when they’re feeling that something ain’t right with a patient … it probably isn’t.

Do yourself a favor and check the patient out. Also, this is a good way to show your nurse colleagues that you respect their opinions.  You hate them because they paged you at 3 am when Ms. Smith wasn’t looking right, but now they’ll love you because you took their concern seriously. And let me tell you newbies: nurse love is the best love when you’re the new kid on the team. Now you won’t get another phone call at 0345h to find out if you wanted to order that “diet as tolerated” by mouth. Not that that has ever happened …

Nurse speak. Nurses learn very quickly how to speak in code to,

  • avoid confrontation
  • make you think something was your idea
  • point out a mistake without being unprofessional
  • make a suggestion without appearing to offer advice

Here are some translations for Nurse Speak.

“Are you sure you want to [fill in procedure, medication, etc.] Mrs. Jones?” means “If you do that you’ll probably kill the patient”.

“Did you say you wanted a chest x-ray on Mrs. Jones?” means “Yo! You forgot to order a chest x-ray, I am going to go ahead and order one now to save you time and not make you look like an idiot when you page medicine and then have to tell them you haven’t done a chest x-ray yet.”

“Oh, I haven’t seen it done that way before, I always thought you had to …” means “Dude you are seriously doing that wrong, please let me show you a better / safer / faster way of doing that”.

And finally, “Did you want me to go ahead and dip that urine for pregnancy?” means, “It appears you’ve left out a major differential, I’m going to make sure it has crossed your mind.”

“Albinoblackbear” is a nurse turned medical student who blogs at Asystole is the Most Stable Rhythm.

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  • Keegan Duchicela

    Agree that experience is key.  The skills that will save your patients come from the four years of medical school, but more so from the 3-5 years of residency after medical school.  FP doctors have over 15 THOUSAND hours of clinical experience before they are allowed loose in the world.  Compare that to 5 HUNDRED to 15 HUNDRED clinical hours that a doctor of nurse practice does (NP).  Not to mention some degrees can be obtained online. Those 3-4 years of residency a physician gets are key in honing that “spidey sense” to know when someone’s sick vs when someone’s big sick.

    • Anonymous

      Gee and wouldn’t that same knowledge from years of nursing work for them as NPs (it’s not like we turn off our years of nursing knowledge when we become NPs). . .

    • Maryann Long

      “Not to mention some degrees can be obtained online.”  Sounds like you feel threatened.  Do you know the difference between a distance education program and an online degree factory?  Do you actually know what’s required to complete an accredited DNP program, which is the same whether the student is on-campus or remote?  No one suggests that a DNP is equivalent to an MD.  The skill set and focus are different and in a sane system the two would work complementarily, not competitively.  The problem is the system.

  • Devon Herrick

    There are parallels between medicine and the airline industry. Thirty-five years ago the airlines suffered several catastrophic accidents. The industry took stock of the events and identified the problem (in part) as a culture and hierarchy where subordinates didn’t dare question the actions of airline captains. The industry established procedures based on experience (sort of like best practices). The solution also involved stripping away the rigid hierarchy and having the crew in the cockpit work as a team.  Everyone’s input was welcomed and valuable. It worked for airlines – accidents fell dramatically.  
    Many experts believe this is what needs to be done in medicine.  The fact that nurses have to use a “code” to communicate patient information to physicians is good evidence that medicine needs to more to encourage a culture of teamwork.

  • http://twitter.com/doctorblackbear Albinoblackbear

    @google-49e9c9ab55e67e8c429e0f6ce33e24ae:disqus I completely agree with your thoughts. It is interesting that you mentioned this as the chapter on aviation from Outliers featured prominently in my mind while I was thinking and writing about Nurse Code. The parallels are easily drawn, indeed! Starting with MD’s being often referred to as “doctor so and so” and the nurses being referred to only by their names.

    The culture of teamwork is one of those abstract concepts that I think many professionals struggle with implementing. Have you read, “The Checklist Manifesto” by Atwul Gawande? Some very fascinating insights and concrete solutions for this exact phenomenon.

  • http://pulse.yahoo.com/_CIYL4OQK3CROGVZOMLUOSG4RHI SchoolBoardLady

    I found this post from a nurse gone medicine
    most interesting from a Myers Briggs perspective.  As a management
    consultant who religiously uses Myers Briggs typology to solve almost every
    communications, performance and management problem, can I suggest that the
    “scary intuitive” skill the nurse is using comes from a long work
    history of using their SENSING preference (observation of facts and detail) to
    the point they have developed their “inferior” INTUITIVE function
    which the doctor may already (innately) have (as the author says book rich
    means “a huge data base of theory and concepts waiting to be linked to the
    patient appearance signs and symptoms).  Imagine the sense of vindication
    that the nurse must feel because through many years of hard labor, the nurse
    now has “pattern recognition” (intuition) after years of using their
    innate sensing preference to catalog “signs and symptoms” where as
    the doctor has minimal “sensing” skills and must work hard to develop
    those sensing skills on the job.  

     

    Thus the reality is that successful business
    people have figured out decades ago–the full brain exists in the TEAM; and highly
    developed intuitives need the highly developed sensors to function competently.
     Now I can’t say for sure the doctor is innately an intuitive and the
    nurse is innately a sensor, but statistics show this to be highly probable, as
    years of schooling and “aptitude” tends to operate as a
    “selection” process that routes intuitives (largest percentage of
    national merit scholars) to medical school and sensors to nursing school.

  • http://pulse.yahoo.com/_JYZSGDUXTNSTJUV5WJB3ZIY23M terminator

    so i assume that when you enter your internship, you will be the most brilliant advice giving doctor-nurse in the whole world??

  • http://pulse.yahoo.com/_7VR3SPRS35TYRD2VQNPXTIUUSY George

    wow. congratulations on propagating a hostile work environment. It makes me sick to see the continual abuse that the nursing culture encourages to be inflicted upon those they see as “weak”, ie med students and residents.

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