People often compare internship to drinking from a fire hose. Overwhelmed by new information and workflow, interns (especially international) usually do not have a clear direction about how to optimize their working/learning experience. Here are some tips for interns to smooth their transition from a newbie into a high-functioning intern in the setting of medicine inpatient wards.
Success leaves clues
Don’t explore yourself, specifically ask your upper-level resident about the most productive resident workflow in your hospital. Residency has been around for decades; you don’t have to reinvent the wheel to be a competent resident. I made the mistakes trying to figure out the process on my own through trial and error in the first few months, whereas I could be more productive by merely asking for the proven recipe. Ask around if some upper-level residents are too busy to show you. Being proactive is key!
Step 1. Arrive earlier before the morning sign-out. First, print out the list, take the sign-outs and ask the night float about his/her plan for the new admit. Then read the chart with an open mind (independent clinical reasoning), allocate 10-15 min for each new admit and 5 minutes or so for each old patient, print the assessment and plan of each patient as a guide for presentation (you will be more thorough and systemic this way), then go out to see your patients. Don’t sit longer than one hour from the sign-out; otherwise, you will likely be late for rounds.
New interns often complain 10-15 minutes may not be enough to review the chart for a new admission. Chances are they are inexperienced and do not know what to read. For me, I used to take 30-40 min to review the chart for a new patient coming in for a straightforward AKI (but with a complicated history and tons of previous chart info). I spent extra time reading extraneous details, which is less relevant to this hospitalization. The solution? Please see Step 3.
Step 2. Go out to see patients, talk to nursing (they usually switch morning shift at the time) about overnight events (get inside scoop to impress your attending since that info is often not in the chart). If you have more time, you can talk to case managers regarding dispositions of patients. Talking to them will enhance your communication skills with allied health care professionals and make you think about big pictures of your patients’ hospital care.
Step 3. Go over the cases, not just the plans, with your upper level and review the labs (they usually come back right before rounds – you must know for making your plan). Most importantly, interns need to get back at least 30 minutes before rounds to seek guidance and run your case with the upper level; this is a crucial step. An IM PGY-2 should have a relatively firm grasp for at least 75 percent of routine cases on the wards. An intern should ask the upper, what and where they look for in the chart (including history and labs) that’s relevant to this case, what the thought process is to arrive at a plan. Once you know that, you will be on the right track of presentation on the rounds with great confidence. If not, interns will likely not fare well during the attending rounds. The less confidence you have for your plans, the more soft-spoken you will be, for which you will be perceived as a weak intern, leading to sub-optimal feedbacks.
Step 4. Reflection, reflection, reflection. OK, you have finally got through the rounds and submitted your notes. However, it’s not over yet! Interns will feel exhausted at the end of the day and can’t wait to relax. Be that as it may, the real difference-maker in your learning curve lies in the quality of your daily reflection. What content area am I not familiar with? How do my uppers and attendings come up with the treatment plan? What are the differences between my thought process versus theirs? What should I do tomorrow to be faster, more efficient, and come up with a better assessment and plan myself? You can not only reflect on their words but also see some clues by reading their addendum to your notes.
Master the fundamentals
The first key to being a productive intern is data gathering, which means you need to extract relevant information from the EHR with speed and accuracy. It’s essential to model after your upper level regarding tricks and shortcuts in EHR use, which will save you tons of time; this is directly correlated with Step 1 above.
Also, solid fundamentals about essential general medicine topics, including labs, X-ray, EKG interpretation, and illness scripts will help you a long way towards an elite intern. With the basic knowledge as a building block, plus the tutelage of your senior physicians as a catalyst, you will understand cases with much more ease and confidence. Resources like OnlineMedEd intern content, MGH Pocket Medicine, etc. (no financial ties to above-mentioned resources) outline the core topics intern must know to develop into a competent resident. Don’t try to spend tons of hours studying clinical trials or primary literature at this stage, master the core first. Just like playing basketball, make sure to hit wide-open 3s before you practice contested deep range shots. Reading should ideally happen during the day instead of the night when you are already tired out. If you execute Step 4, you will know exactly what to read.
Finally, after a whole day of intense work (a large chunk will be computer work), one will feel a strong need to be physical and stretch yourself in the gym to recover from fatigue. A quick game of basketball, tennis or racketball and the like can oxygenate your tissue, facilitate a good night sleep, preserve your energy and vitality. Wearing a blue light filtering glasses while typing notes may also be a great idea to protect your eyesight. Dictating your notes instead of typing it will save you from the repetitive strain of your fingers.
Enjoy medicine, play the long game.
Liang Chen is an internal medicine resident.
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