Starting residency is a very exciting time because after years of grueling education, you have finally achieved the status of doctor. At the same time, residency can be daunting because the work load is heavy, the hours are tough, and the responsibility is much greater. Having gone through much of intern year by this point, I have come up with many tips that can make intern year less scary and, believe it or not, quite enjoyable. To be honest, this has been the best year of my budding medical career to date.
PREPARATION FOR RESIDENCY
Refresh Your Knowledge: If you were like me and took a couple of months off toward the end of fourth year, you may feel that you forgot everything. Prior to residency, there is no need to “cram” because you will start to remember information as you go through the year. However, it would be wise to at least review a few common topics just to jog your memory. I tried to get through a few MKSAP questions about each organ system. This at least got me thinking about medicine topics again. The knowledge will likely come back quickly once you actually start your year.
Review ACLS: Your residency program will require you to learn this, but make sure you continually review. As a doctor, you may be required to show up for codes and possibly take on roles such as recording, performing chest compressions, calling family, or bag-masking. If you are the first to show up to a code, you may even be expected to run it until a more senior member arrives. Make sure you know when to use drugs such as epinephrine, vasopressin, and atropine.
- Have an Efficient Plan: Mornings can be hectic because you need to gather a lot of data before you round. If you are inefficient, you may end up having to arrive at the hospital earlier than necessary. Find what works for you, but you can use my prerounding routine as a guide.
- Come in and log onto the computer.
- Print out the list for the day and figure out how many patients you need to see.
- Start gathering data such as vital signs, labs, imaging results, EKGs, and consults.
- Find your patients’ nurses and ask if there were any issues overnight. Nurses can be an extremely valuable resource, so be nice!
- Look at tele strips if they are on tele.
- Talk to and examine the patients.
- Replete Electrolytes Early – If you still have time, start putting in orders.
- Potassium: Replete K if < 3.5. Giving 40 mEq of KCl will increase serum K by 0.4. If the patient can take po, that is the preferable route. If not, IV is usually okay. If you need to give several doses, give KCl 40 mEq q4h. If K > 5.5, give kayexalate 15g po x 1.
- Magnesium: For Mg 1.6-1.9, give 4g IV over 2 hours. For Mg 1.0-1.5, give 6g IV over 3 hours. For Mg < 1.0, give 8g IV over 4 hours.
- Phosphorus: K-Phos and Neutra-Phos tabs each contain 250 mg of phosphorus. For phosphorus < 2.0, give 250-500 mg po qid.
- Order Morning Labs for Tomorrow: Common AM labs are CBC, BMP or CMP, Mg, phosphorus, and coags. Use your judgment if these need to be ordered. Also remember to order a chest x-ray and ABG for intubated patients.
- Start Notes: Start writing if you have time. Finishing notes early will give you more time for floor work.
- Define Roles: It is critical to assign roles to make rounds more streamline. Whoever is presenting should stay with the attending. Other team members may be listening and simultaneously performing tasks such as grabbing forms, getting consents, and calling consults. Someone may want to walk around with a computer to put in orders and update the list as you go. Don’t be afraid to send students ahead to the next patient to grab charts or have supplies ready.
- Run the List: Remind your senior to run the list so everyone knows what needs to be done.
- Make a Checklist: As an intern, you may be carrying ten patients at a time. In order to remember everything, make a checklist with check boxes for each patient. Be sure to include “order AM labs” and “write note” on the list.
- Delegate Tasks: Have students help you with notes, discharge summaries, and transfer summaries. Just make sure to verify that this work is done correctly. You are expected to properly supervise the medical students.
- Prioritize: Take care of your sickest patients first. Try to call for transfers and place consults as soon as possible. Orders such as medication changes should also be placed during or after rounds. If necessary, notes and updating the list can wait.
- Learn About the Patient: Review the patient’s chart, labs, and previous notes before seeing the patient so you know which issues to discuss. I think patients appreciate when you make the effort to learn about them first instead of just going in blindly.
- Ask Relevant Questions: On call days, sometimes you may be swamped with admission after admission. Thus, learn to hone in on the important questions and tailor your H&Ps so that they are fast but thorough.
- Perform Pertinent Physical Exam: Concentrate on the main issues. But also try to do a general assessment of the head and neck, heart, lungs, abdomen, and extremities. Have a routine so that your physical exams become faster.
- Print a List: Give an updated list to the cross-cover. Write to-dos and important notes on the list to make it easier for the person taking over.
- SBAR: This is a great method for hand-offs. It is quick and thorough.
- Situation: Identify the patient, age, gender, and reason for admission.
- Background: Identify the chief complaint, relevant past history, and brief summary of the patient’s main issues.
- Assessment: Give important vital signs and impression of the severity of the patient’s situation.
- Recommendation: Say what needs to be done and what can be expected. (i.e. This patient may need intubation. Or do not give this patient Ativan). Remember to also address code status.
- Remember You Are Not Alone: Especially when you are just starting, do not feel that you need to handle everything yourself. I think I asked my senior for help with 90% of the calls I received on my first night of cross-cover. It feels overwhelming because you do not know the patients, and the nurses are asking you to manage them. When you become more experienced, you will be able to handle a larger percentage of calls on your own. Potential people who can help you are your senior, other residents overnight, hospitalists, your attending, and the chief residents. Your senior is obviously first line, so ask your senior for help first.
- Try to Limit Alterations in Management: In general, try not to make big changes in medications, such as changing antibiotics. If you must change something, do inform the primary team in the morning. Remember, the main role of cross-cover is to put out fires.
- See the Patient: Sometimes it is appropriate to handle situations over the phone. For example, if a patient is nauseated, you may feel comfortable ordering Zofran over the phone without needing to assess the patient. However, for more questionable situations such as agitation or chest pain, you should assess the patient in person so you do not miss something serious.
- Know How to Handle Common Issues: I am borrowing a lot of this from “Eric and Sonny’s cross-cover cheat sheet” that was given to me during my intern year. This truly helped save me on my busy nights. I have made some modifications and confirmed that the doses are consistent with the current standard of care.
- Constipation: Colace 100 mg po bid, Senna 17.2 mg po qhs, Miralax 17 g po daily, Dulcolax 1 supp PR x 1, Magnesium citrate 150 mL po x 1 (avoid in renal patients), Fleet enema 1 bottle PR x 1.
- Insomnia: Ambien 5-10 mg po qhs prn, Trazodone 25-50 mg po qhs prn, Temazepam 7.5-30 mg po qhs prn.
- Fever: Acetaminophen 325-1000 mg po q4-6h prn (max 1g/4h and 4g/day). Check vitals, get UA, pan cultures, and CXR.
- Agitation: Ativan 0.5 mg IV q4h prn, Haldol 1-2 mg IV q4h prn.
- Pain: Acetaminophen 325-1000 mg po q4-6h prn, Ibuprofen 400 mg po q4-6h prn, Tramadol 50-100 mg po q4-6h prn, Vicodin 0.5-2 tabs po q4-6h prn, Norco 5/325 tab po q4-6h prn, Dilaudid 0.2-0.6 mg IV q2-3h prn, Morphine 1-4 mg IV q4h prn, Toradol 30mg IV x 1.
- Nausea: Zofran 4 mg IV q4h prn, Phenergan 12.5-25 mg po/IV/IM q4-6h prn, Compazine 5-10 mg po q6-8h.
- Hypertension: Hydralazine 10 mg IV q6h prn SBP >180, Labetalol 20 mg IV x 1 SBP > 180, Hydralazine 10 mg po x 1, Metoprolol 25 mg po x 1.
- Hypotension: NS bolus 250-500 cc IV x 1. Repeat if needed. Caution if low EF. If septic, assess the patient and give more fluid!
- SOB/Desats: Check pulse ox, med nebs. Albuterol 2.5 mg inh q1-4h, Atrovent 0.5 mg inh q4h. Consider CXR/ABG.
- Chest Pain: Check EKG, give Nitroglycerin 0.4 mg SL q5min x 3, vital signs, ask about sweating, SOB, confusion.
- Seizures: Ativan 1-2 mg IV q4h prn. Seizure precautions, consider calling Neurology.
- DVT Prophylaxis: Lovenox 40 mg subQ daily, Heparin 5000 units subQ q8h, SCDs.
- Nonsustained Vtach: Check electrolytes, replete K to 4, Mg to 2, and Phos to 4, call code if sustained.
- Afib with RVR: Diltiazem 10 mg IV x 1, then if HR < 110, start Diltiazem 30 mg po q6h to maintain.
- Diarrhea: Check C. diff, fecal leukocytes, stool culture. If acute abdomen, check KUB.
- GI Bleed: NPO, CBC q6h, rectal exam, NG lavage, vital signs, consider Protonix drip, consider calling GI.
- Insulin Sliding Scale:
- Glucose < 60: 1 amp D50 IV x 1, recheck glucose in 30 min.
- 60-80: ½ amp D50 IV x 1, recheck in 30 min.
- 151-200: 2 units Aspart or Lispro
- 201-250: 4 units
- 251-300: 6 units
- 301-350: 8 units
- 351-400: 10 units
- >400: 12 units, call MD, check BMP if suspecting DKA
- Learn to Recognize Who Is Sick – This sounds obvious, but sometimes patients can surprise you. From my experience, normal-appearing patients may decompensate rather quickly. Especially in the ICU, if you have a bad feeling about a patient, tell your senior.
- Review All Organ Systems – In your assessment and plan, write a plan for each organ system. If there is nothing to say, write “no acute issues.” You do not want to overlook something in critical patients. Also try to cover infectious disease, fluids, electrolytes, nutrition, DVT prophylaxis, GI prophylaxis, code status, and disposition.
- Become Familiar with Vent Settings: This is too complicated to go into here. But try to become familiar with different modes such as assist control and pressure support. When reporting vent settings, report the mode, respiratory rate, tidal volume, PEEP, and FIO2.
- Become Familiar with Drips: There are a lot of drips in the ICU. You can read the rate that the patient is currently getting at the patient’s bedside. Try to familiarize yourself with these pressors: levophed, dopamine, dobutamine, neosynephrine, and vasopressin. Also familiarize yourself with versed, fentanyl, propofol, and morphine for ventilated patients.
- Know How to Recognize and Handle Sepsis: You will see this over and over. It is highly recommended to read “Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock 2008” prior to your rotation. http://www.survivingsepsis.org/About_the_Campaign/Documents/Final%2008%20SSC%20Guidelines.pdf.
Keep Up with the Flow: The key to clinic is to keep up with the appointments. You probably have experience with this is medical school, so just try to keep improving your history taking and physical exam skills.
Answer Consults/Pages Promptly: At some institutions, consult services have 24 hours to leave recommendations. The sooner you return a page, the sooner you can get started and meet that deadline.
Have a Good Attitude: Sometimes you may be consulted for something that you think the primary team can handle on its own. While it can be frustrating to get these consults, try to give the primary team guidance. If you do end up accepting the consult, try to do so graciously. They are asking you because they do not know.
Become Proficient at H&Ps: On my busy renal consult elective, there were times that I needed to complete three consults before rounds. Needless to say, my H&Ps became faster. Efficiency is key.
Call/Page the Primary Team for Updates: If you would like a test ordered or a medication changed, let the primary team know right away instead of waiting until the team reads your note in the morning.
Reevaluate Your Role: If the patient’s problem is resolved, sign off to keep your list manageable.
WORKING WITH PEOPLE
You will be working with many people with different roles. Getting along is important for both team dynamics and patient care.
Attendings: We have all had the experience of having an attending who either did not like us or did not pay attention to us. There is not much you can do except be helpful and pleasant. Know that you will get to work with someone else when your rotation ends. If it is really a problem, talk to your Residency Director.
Senior Residents: Senior residents can be very helpful, but occasionally you may work with someone who does not get along with you. This is tough, too, because your seniors are higher than you in the hierarchy. If your senior is giving you a disproportionately unfair share of the work, and you are feeling overwhelmed, say something. If they are good residents, they will help share the load.
Co-Interns: Remember to watch out for each other. Help your co-interns when they need a hand because they will help you when roles reverse.
Medical Students: It makes me sad when I see residents, especially interns, exploiting their medical students. Remember how you felt when you were a medical student. You felt like you did not know anything and that you were always in the way. Instead of seeing medical students as annoyances, see them as an asset to your team. If you have some inexperienced third year students, for example, have them took up a topic relevant to your patient and report their findings to you. Or have them help with notes and H&Ps. Have patience if your students are slow. Like you, they will get better with experience.
Nurses: Be nice to nurses and listen to their concerns. Answer calls graciously. They see themselves as patient advocates and try to tell you about what they think might be important. Again, see nurses as extra eyes and ears for your team.
Pharmacists: They may call you often, but you can learn a lot from the pharmacists. They can save you from administering the wrong dose of a drug.
Introduce Yourself as "Doctor": It may feel weird to call yourself “Dr. X” at first, but patients want to see a doctor, not some guy named “John.” After all this schooling, you rightfully earned the degree and the title. You will get used to it. For attendings, other residents, and medical students, you can call yourself by your first name.
Dress the Part: Find out what is expected for each rotation and alter your wardrobe accordingly. If you should wear scrubs, wear scrubs. If you are expected to wear business casual and a white coat, stick to that dress code.
BALANCING YOUR LIFE
I know I put this at the end, but this is so important. I am enjoying my intern year because I am trying to do other things in addition to medicine. It is certainly achievable!
Make Plans/Engage in Hobbies: Unlike during med school when you needed to study for exams during your “free time,” you now have the freedom to do whatever you want during your time off. Whether that includes visiting family, hanging out with friends, running errands, or even studying (don’t forget Step 3), it is up to you! Make your time off count, and you will be happy.
Have Fun on Work Days: On my busiest month this year, I managed to eat out and go to the movies with my teammates a few times. This was when I was working 70-80 hour weeks. It is possible! Just try to make time, and you can make it happen. Remember, balance is key for preventing burnout.
Anyway, I wish that someone had told me a lot of these things when I first started, so I hope this at least gives you an idea of what to expect as an intern. Intern year is time-consuming, and the learning curve is steep. But with time and experience, you will start to feel more comfortable. As I said before, I am enjoying this year more than any year in medical school. The responsibility is exciting, and you feel that you are actually making a difference by helping patients. Furthermore, you have a job! Good luck with your intern year. And feel free to leave questions. I will be happy to answer them!