Intern Year

Surviving and Thriving During Intern Year

Congratulations! You are about to embark on one of the most memorable years of your life. The next 12 months will undoubtedly be challenging, exhausting, and stressful. But fear not, those who take the information in this section to heart will have the knowledge they need to have an enriching and successful intern year.

Survival Tips

Attend to the fundamental courtesies. Arrive early, dress professionally, and be polite. Treat all members of the health care team, including the support staff, with respect. Do not underestimate the power of kindness.

Stay organized. Methods vary; find a system that works for you. Keeping an active "To Do" list will help you stay sane and maximize efficiency. Write everything down when it is suggested or ordered. You will inevitably get busy and distracted, and hoping you remember to review a lab or reassess a patient is an impractical strategy. Write down test results so that you can quickly recall the specifics when your senior resident or attending asks for them. Find a way to highlight priorities in your notes; some people find a checkbox system helpful; others use colored highlighters or pens. When there are multiple items for follow up during your shift, consider writing out a chronological timeline of time-sensitive action items. This strategy may be particularly helpful during months when you have labs to check throughout the night, such as in the NICU. 

Give (and request) thorough sign-out. "Everyone is stable, there's nothing to follow up" is not responsible sign-out. Give your cross-covering residents a concise snapshot of your patients' history and current status. Know each patient's status when transitioning care to the next team. If you are concerned about a patient's condition, emphasize that to both your fellow intern and the senior resident. Tell the oncoming team about any worrisome developments that you have been tracking and offer a contingency plan for managing possible acute changes overnight. Similarly, when receiving sign-out, ask questions to ensure that you understand the patient's status, active issues, and preferred course of action. Memory is less reliable when one is tired, such as at the end of a shift. For that reason, write down every issue that comes up when on call. Document all interventions or changes in management right away so it is clear who spiked a fever and whose medications were changed. Good notes contribute to a better sign-out when the primary residents return. More important, good records facilitate better patient care. 

Communicate. Sit down with your senior resident and attending at the beginning of each block to establish expectations and get off to a good start. Continue to touch base throughout the month, requesting interval assessments of your performance. Ask for specific examples of your strengths and the areas in which you need improvement. We learn much more from honest and constructive feedback than from a hollow pat on the back. Be sure to incorporate any suggestions as soon as possible.

Read about your patients. Finding time to sit down and study for hours like you did in medical school will be difficult; therefore, take every possible opportunity to learn as you go. Even the most straightforward patient can be a learning opportunity. Challenge yourself to learn from each experience; even your 20th patient with asthma has something to teach you!

Utilize your resources. The fact that you are now officially a doctor does not mean that you are supposed to know all the answers. Ask for help! If you are not comfortable making a decision or assessing a patient, lean on your senior resident, nurses, respiratory therapists, and other qualified staff. The biggest mistake you can make as an intern is to misjudge a situation and subsequently face an avoidable unfavorable outcome.

Embrace your role as a teacher. Although you will likely be overwhelmed by the increased responsibility and patient care load, one of your most important duties as an intern is to help teach your medical students and fellow residents. Lead by example. Incorporate clinical pearls on rounds, bring evidence based articles to rounds to help guide patient care, pull students aside after rounds to review their documentation, or give a quick talk on some fundamental pediatric topics you're comfortable with. Think of the best residents you worked with as a student, and emulate what made them so great to work with. 

Find a Good Mentor 

Many residency programs have a structured mentorship program built into their curriculum, but don't let that limit you. Like patients, mentors come in many different shapes and sizes, and you can learn from all of them.

Formal mentoring is usually best provided by a seasoned faculty member. In general, the goal is to be paired with a mentor who shares your professional interests and has a wealth of knowledge in your desired field. However, many incoming residents have not yet finalized their future career plans. Experiences during intern year will largely influence the decisions to specialize, and if so, in what field. An experienced mentor in any specialty can be an invaluable resource, providing not only information but less tangible support through the challenges of residency. From academic to personal to career-oriented issues, a mentor can provide impartial and confidential advice. If your program does not offer an official mentoring program, be your own advocate and seek one yourself! Don't be afraid to approach an attending you enjoy working with and ask him or her for advice and support. Also, senior residents, chief residents, and program directors are excellent sources of informal mentoring. Remember, knowledge is power! Being proactive and asking questions can help reduce a lot of the anxiety that accompanies all the "firsts" of intern year. Practical knowledge from a veteran is sometimes worth more than anything you read in a book!

Tips for That First Night On Call

Remember, you are not alone! Nurses can share a wealth of information and can help you prioritize what you need to do. Whether by phone or in person, you always have backup from a senior resident, fellow, and/or attending as well.

Get a good sign-out. Ask if there are any patients the team is particularly worried about and what issues they anticipate. Prompt the team signing out: Are there any patients in distress, requiring oxygen (how much?), or who may have concerns overnight? What is the "fever plan" should a patient develop a fever? Are there any labs or imaging studies that need to be followed up on? Try to see those patients that the previous team had concerns about briefly right after checkout to get a baseline on their clinical status. It may also be helpful to ask for a separate sign-out from a nurse manager on patients he/she is worried about. This may reveal other potential issues that could arise overnight.

Organize. You will have a lot to do, so create a system for keeping track of tasks. Keep a running list of things to do (e.g., things to follow-up on from admissions and calls you received on patients during the night) and check things off as you complete them.

Communicate with the nursing staff. When talking with nurses, don't forget to ask about medical conditions, vital signs, weight, or allergies if you are unclear about how these could impact your decision-making. Nurses often have a wealth of information and experienced nurses can often help you to decide how best to proceed. Knowing the nursing assessment and plan can be quite valuable. 

Communicate with families overnight. Update families overnight if there are changes in their child's clinical status or new interventions being made. When appropriate, a sleeping parent should be awoken if there are major clinical concerns, new medications being given, or changes in management. Use your judgment when it comes to when to wake parents up to update them, and always err on the side of informing parents rather than not informing them. 

Prioritize. When nurses call with a concern, ask them to clarify the urgency and whether the matter requires an immediate in-person assessment. If it is less urgent and you are in the middle of an admission or attending to something with higher acuity, be honest about when you will be able to address their concern. Ask them to page you back if things change or with further updates. Getting a set of vitals on a patient over the phone can be reassuring when you are busy and unable see the patient right away. 

Assess all patients you are called about! If a nurse or parent is concerned, you should be too. Don't just patch a symptom. Really think about what could be going on and what steps you should take. For example, perform a full physical assessment when a child develops a new fever instead of just ordering acetaminophen over the telephone. 

Document. Because those on the next shift may wonder why you made specific interventions, include your reasoning in the patient's chart. Also document assessments made throughout the night. These can be abbreviated incident notes or SOAP (subjective/objective/assessment/ plan) notes. (For example: S - Called to assess itchy rash in pt without facial swelling or difficulty breathing; O - VSS, HEENT exam reveals no rash or swelling, heart RRR, lungs CTAB, unlabored respirations, no wheezing, skin reveals diffuse 1-2 cm pruritic erythematous patches that blanch; A - Assessment: Urticaria; P - Plan: Diphenhydramine, will follow as needed.) Careful documentation promotes patient safety, is appreciated by your colleagues, and may prevent a post-call page to you. 

Avoid mistakes. For example, when writing an order, especially a prescription, always double-check it. Focus on the task at hand. 

Know when to ask for help. It is normal and appropriate to ask for help often at first. Seek help from the nurses, from your senior resident, your fellows, and from your attending. Remember, they are there to help you and help the patient. If a patient is getting worse, notify your team and others who are also responsible for the patient.

Be ready for a nonstop night! Consider having the following items in your white coat pocket or readily available: a good general pediatrics reference, a pediatric drug reference, your stethoscope, and anything else you may need that may not be kept in your patients' rooms (e.g., tongue blades, ear specula, flashlight, otoscope, and ophthalmoscope). Strongly consider having a snack, gum, and a toothbrush as well! A snack break or quick freshening up might really help you reenergize. Finally, have your pediatric advance life support (PALS) algorithms readily available at all times.

Attend to the basics. Two hours of sleep and a quick shower make a world of difference when you have to stay sharp the next day, but you won't always get them. If you end up with free time, sleep! Also, don't forget to eat healthy snacks to keep your energy up!

Keep an open mind. It can be difficult to gracefully accept feedback in your sleepy post-call stupor. Listen, repeat the concern, ask how things can be better approached next time, and thank the person giving your feedback for the advice. Remember, people who give you feedback are trying to help you improve – you have that as a shared goal. Think of feedback as "formative" (helping form you into the doctor you want to be) rather than "summative" (an evaluation of the doctor you are or judgment of your weaknesses). You don't have to agree with the feedback being given to use this method of handling feedback! To really be stellar, follow up with the individual who provided the advice at a later time to ask if they have seen improvement.

Remember, as they say "This too, shall pass." Everyone has experienced a first call night with the same anxiety and uncertainty. Call nights can be overwhelming, but they get better! Residency is a marathon, not a sprint!

The key word is anticipation. At every phase of care, from your initial assessment to discharge planning, always try to think a few steps ahead. This is one of the biggest differences between being a medical student and being a successful intern. Try to predict what questions your senior resident or attending will ask, what problems your patient could develop, and what treatment needs may arise. Don't get tunnel vision and forget about follow-up plans, ancillary therapies, pharmacy issues, and family education. This applies to both inpatient and outpatient settings.

Reconcile your charts daily. Make sure you are aware of all standing lab orders, cultures, and medications. Scrutinize each one to ensure that only necessary and clinically relevant therapies are employed. Discontinue PRN medications that are not being used or could potentially interact with other medications. Realize that your patients do not enjoy needle sticks and look for opportunities to minimize their lab draws.

Scrutinize everything. Take nothing at face value; investigate everything yourself. When called because a patient's status changes, go to assess the patient – even if it is the middle of the night. If a family is not sure of a medication dose for a newly admitted child, call the pharmacy or prescribing physician. Whenever possible, do not rely on hearsay or supposition. Be your own eyes and ears.

Have a plan. As discussed previously, there is nothing wrong with asking for help. When an issue arises, identify and gather data that is relevant to the problem, research potential answers, and present a proposed course of action to your supervising resident. For example, don't simply say, "The nurse called me because the patient's blood pressure is low, what should I do?" Go to the bedside, assess the patient, review the flow sheets, gather the blood pressure readings, anticipate possible questions from your senior resident (such as checking that an appropriately sized cuff is used, rechecking the blood pressure personally, assessing ins/outs, and determining what medications the patient is on), and make a suggestion (such as giving a fluid bolus).

Lead the way. Actively interact with your consultants and ancillary providers such as respiratory, speech, physical, and occupational therapists. Use all available resources to ensure that your patients are receiving the best possible care. Your job is to be the captain of your patient's team, the person who assimilates and integrates information from all relevant sources. Keep everyone informed of the patient's condition and promptly employ suggested recommendations. These steps can help decrease the length of hospital stay and improve outcomes. When caring for hospitalized patients, communicate with their primary care pediatricians.

Communicate with the patient and family. You should see your hospitalized patients multiple times each day. Keep in contact with the family, update them often, assess their needs, answer their questions, reassure them when appropriate, and provide them with education. Families will appreciate the extra time you spend to help guide them through what is probably a frightening experience. Try to place yourself in their position and let the insight from that perspective guide your interactions. 

Patient Ownership 

When you think about responsibly taking ownership of your patient, think about the relationship you expect to have with your doctors.

Remember to relate. Try to remember the experiences you or your loved ones have had in the past. Patients are anxious, feel crummy, and want to know what is wrong with them and what their medical team is going to do about it. They want to know the plan before it is executed. No one enjoys learning that labs are going to be drawn when the nurse arrives to draw them! They want cost effective care with minimal, or at least disclosed, side effects. They also want to be listened to and treated with compassion and dignity.

Take ownership of your patients' care. An attitude of ownership reflects a philosophy and an attitude about your role and responsibility to your patients. It takes practice and commitment. The reward for this commitment is the satisfaction found in caring for your patients, seeing their gratitude, and earning the respect of your senior residents and attendings, which will translate to more autonomy.

Know all there is to know about your patients. You should know more than all of the consultants and even the primary attending. It is difficult for interns to balance patient ownership with work demands and duty hour restrictions, but this is what your fellow interns, senior residents, attendings, patients, and families will expect! Have the facts readily on hand (if not memorized). Details can save patients from redundant, invasive, and expensive workups. When the clinical picture is not making sense, these details may be the clues that reveal the diagnosis. 

Remember that you are the patient's primary doctor, not a messenger or secretary to their attending. You are the one who coordinates the patient's care! In fact, the more consulting attendings involved, the more the patient needs you to sort out the potentially conflicting messages. Take pride in caring for your patients and knowing them better than anyone else. Consult other physicians wisely. Even when you consult another service, challenge yourself to figure out what is going on before the consultant simply gives you the answer. 

Keep the family updated. Explain evaluations and treatment in advance! Ask the family what questions they have and let them know you are available if they need you. Tell them about results promptly. After a lumbar puncture, let them know how it went. Share and explain the CSF findings right away. If you don't know something, be honest with them. They will appreciate it. Most patients and families understand that you are learning. Let them know you will help them find the answers to their questions so you can learn together. Teaching directed at families and patients is at least as important as teaching medical students. If you bring the medical student with you to talk with families, you can even teach everyone at once! 

Expedite patient care. Decreasing hospital length of stay is a worthy goal. Don't keep that patient in the hospital for an extra day and $1,500 more because one test is not yet complete. Anticipate needs, manage, and coordinate care aggressively. Be the advocate for your patients and their families. Pull the old chart from medical records or have the patient's family sign a release from the other institution. Advocating for your patients, mobilizing resources for them, and expediting their care may require a few telephone calls. Be creative and make things happen! 

Be accountable and responsible for patient care. You are supervised and will have to report most of the things you do with senior residents and attendings. Discuss your diagnosis, differential, and plan for evaluating and treating the patient. It is fine to be unsure and ask for help, but start by disclosing what you are thinking. This will allow your senior residents and attendings to see your thoughtful investment and give you feedback. If you are concerned that a patient's treatment may not meet the standard of care, respectfully discuss your concerns and reference evidence-based medicine guidelines, if they apply. Sharing your concerns openly will either achieve better care for your patient or be a great learning opportunity for you (or both!). Welcome feedback and let yourself be molded into an amazing pediatrician!

Be ready with a systematic approach when you call on your senior or attending in the middle of the night. Prior to calling, have the patient chart and flowchart of vital signs readily available, assess the patient, and think critically about what you think is going on, why, and what you would like to do. Present the concern or question in the SBARR format (describing the Situation, the Background information, your Assessment, and your Recommended action, then allowing time for a Read-back to insure both parties understand). Finally, process and document their response. 

Signout: Be the Key to Your Patient's Safety 

At the end of your shift, tie up loose ends and ensure a smooth transition of your patient's care. The residents coming in to replace you will likely be able to tell that you have been up all night and will have some mercy on you. It's okay to be human at the end of a shift, but fatigue doesn't excuse any team members from having foresight. Don't leave that extensive discharge on your chronic patient for the cross-cover team to complete. Get it ready in advance for the benefit of your patient and your colleagues. When you leave, ensure a good sign-out on your patients -- one that includes trouble shooting ("if this happens, do this") for the on-call team. On the flipside, when you are cross-covering and on call, ensure that you are receiving enough information to provide exemplary patient care in the primary residents' absence, because when you are on call or cross-covering, patient ownership continues. Remember, all of the patients are YOUR patients! Caring for each patient requires a team effort and good communication. When you write an order, make sure the appropriate people know about it (nurse, pharmacist, patient and family, etc.) and follow up to be sure it is completed. When it comes to your patient, lead the team! 

Good Signs

  • Nurses know you as someone who is complete, attentive, competent, dedicated to your patients, and certain to get things done!

  • Patients know you as their doctor. When a consultant asks the family who their physician is, the family will give your name!

  • Things are taken care of and everyone is updated when you leave. The on-call team will not be paged to explain everything to a family because you will have already taken care of it. Changing of the guard happens for families too. Many people recommend that families buy a notebook to keep track of things, or write their major questions on a whiteboard in the patient's room. This can be helpful when different relatives come and go throughout the day and night.

  • Discharges go smoothly, patients understand what happened during their hospital stay, and they can effectively follow their discharge instructions and relay them to their primary physician at their follow-up visit. Although patient understanding is important, call your patient's primary outpatient doctor to be sure he or she knows what happened with the patient under your care and what the plan was at the time of discharge. 

Studying During Intern Year

  • Read about your patients' conditions!

  • Read journal articles relevant to your rotation and your patients.

  • Attend conferences and lectures that are designed for you! These conferences are intended to enhance your learning, so don't let the work of the day prevent you from attending. The work will still be there after the conference, so make sure to attend unless you have acute patient care needs.

  • Pediatrics in Review is a great resource! As a resident member of the AAP, you will receive this online monthly. The review articles in this publication are high-yield, concise, easy to read, and written by content experts. Try to read every month's edition. This is great general learning as well as board review because the topics of the Pediatrics in Review articles are based on the American Board of Pediatrics general pediatric boards content specifications. In fact, 5 years of Pediatrics in Review covers the content specifications of the boards exam.

  • The AAP publishes PREP® questions each year. These questions are written in pediatrics board style and cover the content specifications of the general pediatrics boards. You will have access to these questions online at PediaLink (the AAP online learning site). These questions are a great way to review pediatric topics. Answer a few questions per day or a block of questions during a slow shift and you will become one of the many residents who use these questions to help prepare for the in-training exam to be taken each July during residency.

  • Talk to your program leadership or mentor near the start of residency to map out a plan for boards preparation. Much like the other learning that occurs during residency, preparing for boards is a marathon, not a sprint! There is no need to stress about boards during the first week, but it is smart to develop a plan early on to review routinely throughout your years as a resident. 

Bottom Line 

The intern year is meant to be challenging. Taking ownership of patients will be difficult at first. However, with organization, focus, consistent documentation, and a willingness to ask for help, the intern year can be extremely rewarding as well.

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