The intern who knows everything

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What seems like a tidal wave of pages washes over you. Drowning in a torrential sea of order clarification, bowel regimens, and vital sign deviations — you struggle to stay afloat. Medical school did not prepare you for this. Patients and nurses are calling you, “doctor,” you wish to return to that minimal responsibility role as a medical student.

Welcome to your first on-call weekend.

These first few days, weeks, and months are filled with clinical hesitancy as we begin to test this newfound freedom and with it, feel the consequences of our decisions. It seems like every small aspect of patient care needs to be verified by a senior resident. Living in a constant state of uncertainty, we are humbled by the mantra, “You don’t know what you don’t know.”

This ritualistic pattern repeats itself each year. However, as with any new experience, patterns begin to emerge, and confidence begins to blossom. That internal voice begins to say, “OK, you got this,” as pages about pain management and discharge expectations roll in. Hypertension, oliguria, altered mental status, chest pain, dyspnea, and post-operative fever begin to fall into newly formulated decision-making algorithms. Associated clinical assessment protocols are developed.

Establishing differential diagnoses and enacting a plan becomes a day-to-day occurrence. And of course, all things are “bumped up” to the senior resident, but the intern who was once the reporter begins to evolve into the manager. Naturally, each successful patient management encounter builds confidence. Questions and pages that were once sheepishly directed toward senior residents are now fielded, assessed, and a decision is made by the intern.

Four or five months into internship, the new residents come to a natural, yet dangerous point: assuming small variations from the norm are erroneous rather than true.

Convincing yourself that the patients are healthy rather than assuming they are sick and ruling out that they are not. At first, every page about hypotension or new post-operative pain mandated a visit to the patient’s bedside. Now, bolstered by the confidence established through multiple previously successful patient encounters, we begin to make clinical assumptions. We assume that the one temperature measurement that was above 38.4 was a mistake. The hypotensive blood pressure reading must be due to a cuff size mismatch. The hematocrit has been drifting down slowly over the past few days; the anemia must be dilutional.

Comfortability breeds complacency. Complacency leads to assumptions, and assumptions cause misses in patient care. Insidious as it may be, this process manifests itself in the new intern as we are inherently programmed to assume patients are healthy rather than sick optimistically. Even when signs or symptoms manifest, albeit in an uncharacteristic pattern.

Restoration of one’s humility will be quick in these moments. A swift reminder of the infancy of his/her career and the lack thereof clinical gestalt will be delivered unapologetically as the patient’s clinical course unravels. Although the depth of the pit formed in one’s stomach feels unfathomable, it will fade, but momentarily, serve as a reminder of how much there is yet to learn.

From my own experience, I was paged at 0500 at the end of my night-float shift about a stable patient who had a near-syncopal event after rising from bed with the nurse. His vital signs at that time were normal, and he had a non-focal neurological exam.

As I walked to the patient’s room, differential diagnoses came to my mind. I assumed it was likely orthostasis leading to a near-syncopal event because the patient had poor PO intake over the past 24 hrs. He was an elderly gentleman, and I assumed this fit with the idea that he was hypovolemic, under-resuscitated with age-related autonomic dysfunction. His labs drawn an hour and a half earlier revealed a stable hemoglobin/hematocrit, 8.6/26. The patient appeared normal when I arrived, but after a minute became unresponsive. He was pale, diaphoretic; his extremities were cool and clammy. We laid him back in bed, and I realized this was much more than what I assumed. His next blood pressure measurement was 64/40 after initiating a rapid response, resuscitating him with 1L of LR. His labs returned with an H/H 5.9/18 and a lactic acidosis at 3.7.

This patient was on postoperative day six, following an open right hepatectomy. He was hypotensive, hypovolemic, and clearly bleeding. But a hepatic source seemed unlikely. It was only after my shift had ended, I returned later that evening to learn he had a massive GI bleed, received eight units of packed red blood cells, was transferred to the ICU, intubated, invasive monitoring instituted, and scoped from above and below.

Thankfully, I was able to call on my second-year colleague, the ICU nurse, and ICU attending to manage this patient. Had he been discharged the day prior as planned, he would have likely died. I had no idea why he presented the way he did, and I was not only completely overwhelmed but also felt helpless as the situation requires greater medical knowledge than I had. I didn’t know what to do.

To the intern who knows everything, quickly will you learn the limits of your knowledge and the sting of complacency. Humility will be served cold. Countless times throughout residency, you will be reminded that you don’t know what you don’t know, which insidiously makes itself apparent. Appreciate your limitations, stay humble, but most importantly, do right by your patients, even if that means admitting you are wrong.

Jason Lizalek is a surgery intern.

Image credit: Shutterstock.com

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