Advice for Internship

My mother would have called this post back-assward. On a recent stint on our inpatient general medicine service, I handed out my “Advice for Internship” index card. I assumed I had written a Sensible Medicine post expanding on these nine recommendations that I could send to the team. However, when I looked it up, I realized I had written “Advice for Internship 2.0,” a post that only references the contents of the card. So, here is part I. An updated version of Advice for Internship 2.0 will follow next week.

I came up with this list by reflecting on what did and did not work for me during my training – at least when viewed from the proverbial retrospectoscope.

1. Immerse yourself – residency is when you get your 10,000 hours​

Ok, I know that the whole 10,000 hours to develop expertise thing from Malcom Gladwell’s Outliers has been debunked. But it is true that getting good at anything – horseback riding, poker, practicing medicine – requires lots of time and repetition. The time and deliberate practice of internship will pay off for your entire career.

You can only spend the time to get good at something if you truly love it. It says something about me that, at some point, I got pretty good at hitting curve balls, practicing medicine, and identifying 15^th century Italian art but never got good at playing the clarinet or painting with water colors. If you don’t love the work, and putting in the time is sheer drudgery, now is the time to find something else to do. If that is what you should do, changing course will be hard and will take courage, but it will be the right decision for you and your would-be future patients. Nothing guarantees burn out more than doing the wrong job.

2. Really listen to the nurses, pharmacists, therapists, chaplains…​

More than during any other time in your career, you will work closely with professionals whose careers are dedicated to caring for the sick. They have a ton to teach you. You will learn medicine, interviewing, philosophy, and empathy. In my experience, the only thing our colleagues ask of us, in order for them to generously share their knowledge, is the attention and respect they deserve.

3. On your way home, think about each one of your patients

When I first posted this list on twitter, twitter being twitter, I got a lot of grief about this one. “Don’t think about your patients on the way home. You need to take a break!”

I disagree!

This is part of your 10,000 hours. This is part of deliberate practice. I can still remember a drive home during July of my internship. My resident told me to decrease someone’s maintenance fluids from 125 to 120 cc/hour. I forgot to make the change. I worked through the math:

Over the 10 hours, how much extra fluid would the patient get?

How much would be intravascular?

How great was the risk?

Was it worth paging my co-intern?

Was it worth turning around and going back to the hospital?

The fact that I remember this and can still recreate my reasoning tells me how much I learned from this post-work obsessing.

These days, as a “grown up doctor”, I have solved many diagnostic dilemmas or therapeutic puzzles on a run or during a swim.

4. Reflect on the practice of doctors you work with, you can learn from everyone

During your time as an intern, you’ll work with dozens of residents, fellows, and attendings. Some these doctors will impress you. Be mindful as you watch these people practice. From those people who impress you, those who manage teams well, those whose empathy seems genuine, those who seem committed to their work for the right reasons, are there behaviors you can emulate?

You will also work will some people who you will not be crazy about. Learn from them too. Avoid doing the things they do wrong. Appreciate what they do well, there will be something.

5. Never hesitate to return to a patient’s room for more information or to change your plans if you have new ideas

“Ms. Peter, I need to ask you one more thing.”

“Sorry to bother you again Ms. Peter, but can I look at your knee one more time?”

“Ok, I promise I will let you get some rest after this. Can you take me through when your symptoms started one more time?”

These revisits can be embarrassing. But if you are really going to learn, you have to accept some humiliation. Even after 30 years, I never do everything right during an encounter with a patient. I never get all the information I should. It’s often hours later (often on the walk home when I am still thinking about my patients) that I remember something I wish I’d asked. It is one of the privileges of being in the hospital so much that a “follow-up visit” usually just means a walk down the hallway. The information obtained can save a lot of time, and money, and unnecessary testing.

6. Patient care is hard, and people will ask more of you than you can ever give – be strong, resilient, and take care of yourself​

There was a month during my internship that still ranks as the low point in my life. I was exhausted; I was faced with pain, sickness, and death; I couldn’t possibly help all the people who wanted me to; I knew there were other people who could do the job better than me; some people were angered by my shortcomings.

I am not sure I could have done any better than I did. What did get me through was a realization that it was supposed to stink, that it would get better, and that I could rely on the companionship and support of colleagues, friends, and family.

7. Spend your free time doing the things you love with the people you love​

It probably cheapens this to expand on it. You will have time out of the hospital. Spending the time intelligently is the most important aspect of self-care. In The Overstory, Richard Power writes, “I never knew how strong a drug other people are.”

I learned that during internship.

8. Care for your colleagues​

This follows pretty clearly from six and seven. Between three and four hundred doctors commit suicide every year. Three medical schools exist just to replace the doctors who kill themselves every year. Always ask after your colleagues. Provide support when you can, help them find it if their needs are more than you can fill.

9. Post call, put on clean socks

A pair of cool, clean socks is worth about an hour of sleep.

Photo Credit: Jonathan Borba