The calendar has turned to June, another class of medical students has graduated, and they will soon begin their residency training. What better time to dish out some unsought advice.
This is a lovely post. My internship was a surgical transitional year from 1988 to 1989, long before the weekly work hours limit was instituted. This is a particularly special time to recall my internship year because my son just started his Family Medicine residency. Though tempted, I won't go down the "when I was an intern" route; I've left him mostly alone. I will keep your wise words on hand, though, in case I have the right opportunity to pass them along. Thx.
I did my internship at the same hospital I rotated during med school. It was a at a BIG County Hospital so I knew the territory and I knew the people. MS 3 and 4s were considered just another intern.,
At that time we didn’t have phlebotomists, IV nurses, PICC lines or pharmacists. We were figuiing out our kanamycin and gentamicin dosing ourselves, carbenicillin was the breakthrough antibiotic for the odd Dread Pirate Roberts Pseudomonas. Cephalolthin was the Staph Drug of choice. Pharmacy sent the ampicillin vials and the nurses spiked and diluted the powders and hung it. They used the second hand on their watches to time the number of drops per 30 seconds and then figured out the infusion rate. Medication orders were carbon copies sent to the pharmacy. Central lines were 16 gauge catheter-over-needle 6.75 inch cathteters and the approach as always subclavian which gave you the opportunity to learn how to place a chest tube. Sterile technique for central lines was a swab of betadine with no time to wait for it to dry.
That was almost 50 years ago and I know things have changed A LOT since then. My first call day, the first day of my internship as an Internal Medicine intern began on a Wednesday at 8:00 AM. Admitting began at 4:00 PM and lasted until 8:00 AM Thursday. I got back to my apartment at 9:00 PM. and was up again on Friday at 7:00 for 7:30 AM rounds. It was like that evey 6th day for a month.
I have no idea what to tell a new intern other than to read, read, read, pay attention when someone smart (you can figure out pretty quickly who they are) tells you something, read, read, read, and that its a real person, with a family and a life, whose well-being you are being trusted with.
This is thoughtful, humane advice, particularly the emphasis on humility, learning from the entire healthcare team, revisiting patients when something does not feel right, and caring for colleagues. The reminder that residents are not expected to be excellent immediately is especially important.
At the same time, some of this advice is reminiscent of what I heard from my own mentors in the early 1990s. These were the physicians who joked, “There is only one problem with being on call one in two: you miss half the good cases.” It reflected a culture in which exhaustion, self-denial, and total immersion were often treated as signs of commitment.
Combined with the typical Type A, perfectionistic, and sometimes obsessive personality of many medical students and residents, that culture had serious consequences: poor physical and mental health, suicide, the loss or breakdown of intimate relationships, burnout, and widespread dissatisfaction within the profession.
For that reason, I would place much greater and more concrete emphasis on protecting one’s own health and relationships during training. “Take care of yourself” is easy to endorse but difficult to act on unless it is made specific: sleep as much as the schedule permits, eat reasonably well, exercise even if it is only a walk around the hospital, and be cautious about escalating caffeine use. Residents should also be explicitly warned against using prescription stimulants or other substances simply to push through prolonged sleep deprivation.
There is also a potential downside to advising trainees to think through every patient on the way home. Reflection can be valuable, but it can also become rumination and prevent psychological recovery. A brief, deliberate review may help; carrying the entire hospital home every night does not.
Finally, residents should protect the important people and events in their lives. Learning medicine matters enormously, but significant others, family, friendships, and one’s own physical and mental health cannot consistently remain at the bottom of the list. Missing every meaningful event for the sake of training is not proof of dedication. Over time, it is a pathway to burnout, resentment, and dissatisfaction, and may ultimately make someone a less effective physician.
Clean socks help. Sleep, health, boundaries, and sustaining a life outside medicine help considerably more.
After medical school, check to see if they still have a pulse. They must still be human if they are going to learn anything in actual practice, residency
When I was Chief Resident I counselled new interns to avoid making major personal life decisions during what will be the most exciting and stressful year of their lives. Don't marry, divorce, buy a house or have a child if you can possibly put these off for at least one year. The added stress of these types of decisions can be overwhelming in the internship year.
Hi: I need help from people who love science! Can data center cooling loops recycle electricity from condensation as MIT's groundbreaking 2013 experiments suggest?
As data centers face an unprecedented energy and cooling crisis driven by AI infrastructure, billions are being spent on managing thermal phase changes—specifically evaporation and condensation.
In my latest work at Decoding Science, I’ve outlined a simple backyard citizen-scientist experiment that suggests we fundamentally misunderstand electron behavior during these phase changes. Standard solid-state models predict a neutral net current during condensation on these surfaces, but geometric manipulation reveals a measurable electrical anomaly.
If this anomaly scales, it means the massive humidity and condensation loops already running inside data center cooling infrastructure could be harnessed to harvest electricity directly from waste heat. Perhaps equally significant is how understanding evaporation will facilitate the cooling process.
I’ve laid out the simple, reproducible experiment to prove this effect. Would you be interested in a brief look at how rethinking electron kinetics during condensation could impact the future of data center efficiency?
From a nurse, I really liked #2. I would say to follow that even once you are done residency. Physicians are not out there alone. There is a whole team taking care of that patient - use the team, be a team player.
From a retired physician, remember that it is a privilege to care for another person. Be grateful every day for this blessing to connect with other people and enjoy it. Ultimately the days go by so fast and the next thing you know....you're retired.
I LOVE that replacement of the adage "medicine is an art" with "medicine is a craft"!! My brother is an artist, and he objects when I say "medicine is an art." I will have to change the saying and see what he says!
This may be dated: Never write anything in the notes that would be embarrassing if read in court. Things like "FLK" for funny-looking kid. or "Attractive female, appearing stated age". Keep descriptions accurate, but dry.
"If read in court"! Why use that as your measure? Patients all have access to their own chart notes - most of us never get to court but your patients read your notes. Don't write things that would be insulting, demeaning, misunderstood, etc. May not be as true in small EHR, but Epic notes are read by all. Stay professional!
Decades ago. before we had all these useless things like vaccines to prevent meningitis and before ER was taken seriously (I was told to do a 2nd residency because this ER thing would never work out.) I worked with a pediatrician who was not very doctorly/dignified. His notes (Objective) would start, in this case, with "Alert child, running about the room. Mom and I had to corral him When on the exam table, we had to retrieve the exam table paper from his mouth; no harm done." When subsequently sued for missing meningitis, the plaintiff "expert", having expounded on how desperately sick these children are and how, if they had just sought him out, the child would now be a Rhodes scholar, was asked to read aloud the contemporaneous chart entry. He folded.
I still follow this lead, charting a salient observation or 2.
I belong to another time and come from a culture known for its colorful language. My residents (and patients) like my notes because they succinctly capture the issue in a way you can remember. And don’t worry about the lawyers. I’ve defeated the best of them. All you have to do is look the jurors in The eye and expound. They love to be talked to like fellow humans.
Never read an Epic note that really informed you about that patient that day. My favorite Epic note was at a follow up visit for a rash. It was from the week before and was six pages of Epic babble and the diagnosis was “rash.” I asked the patient to show me the rash. The six pages Epic note was updated with one word—shingles.
I still think the "never put anything in the notes that would be embarrassing if read in court" still holds in almost the inverse fashion - if you document, say, "2+ dorsalis pedis pulses" in an amputee, "good judgment" in a comatose patient, or "no rashes" in a guy with cellulitis, that is embarrassing.
If you "document" false or invalid information, I think it calls into question the validity of the entire note! Unfortunately, it is a side effect of the charting requirements and habits that have been at play over the past 10 years. Most notes are copy/past, templated garbage or fluff. Most of the time, I'm wildly scanning for any tidbit of truth, assessment, guidance.
Templates are great, but in my experience, interns are not ready for them. My advice is to treat templstes like a privilege once ypu have mastered the art of the SOAP note. This appears to be a dying art, due to the ubiquitous use of templates, which are rarely accurately and completely updated to match the patient situation, especially by new physicians and practitioners.
I fear nowadays almost the opposite is true. All the notes are auto-generated templates, 99% filler. I would almost challenge the opposite - "include at least one detail in the history or physical that demonstrates that either you or the patient (or both!) are actually human."
But, yeah, that can get dicey if you lack prudence. :-)
This is a lovely post. My internship was a surgical transitional year from 1988 to 1989, long before the weekly work hours limit was instituted. This is a particularly special time to recall my internship year because my son just started his Family Medicine residency. Though tempted, I won't go down the "when I was an intern" route; I've left him mostly alone. I will keep your wise words on hand, though, in case I have the right opportunity to pass them along. Thx.
Wonderful piece. Can you provide documentary evidence that you were really good at hitting the curve ball?
I did my internship at the same hospital I rotated during med school. It was a at a BIG County Hospital so I knew the territory and I knew the people. MS 3 and 4s were considered just another intern.,
At that time we didn’t have phlebotomists, IV nurses, PICC lines or pharmacists. We were figuiing out our kanamycin and gentamicin dosing ourselves, carbenicillin was the breakthrough antibiotic for the odd Dread Pirate Roberts Pseudomonas. Cephalolthin was the Staph Drug of choice. Pharmacy sent the ampicillin vials and the nurses spiked and diluted the powders and hung it. They used the second hand on their watches to time the number of drops per 30 seconds and then figured out the infusion rate. Medication orders were carbon copies sent to the pharmacy. Central lines were 16 gauge catheter-over-needle 6.75 inch cathteters and the approach as always subclavian which gave you the opportunity to learn how to place a chest tube. Sterile technique for central lines was a swab of betadine with no time to wait for it to dry.
That was almost 50 years ago and I know things have changed A LOT since then. My first call day, the first day of my internship as an Internal Medicine intern began on a Wednesday at 8:00 AM. Admitting began at 4:00 PM and lasted until 8:00 AM Thursday. I got back to my apartment at 9:00 PM. and was up again on Friday at 7:00 for 7:30 AM rounds. It was like that evey 6th day for a month.
I have no idea what to tell a new intern other than to read, read, read, pay attention when someone smart (you can figure out pretty quickly who they are) tells you something, read, read, read, and that its a real person, with a family and a life, whose well-being you are being trusted with.
Enough shouting at the sky for this old man.
This is thoughtful, humane advice, particularly the emphasis on humility, learning from the entire healthcare team, revisiting patients when something does not feel right, and caring for colleagues. The reminder that residents are not expected to be excellent immediately is especially important.
At the same time, some of this advice is reminiscent of what I heard from my own mentors in the early 1990s. These were the physicians who joked, “There is only one problem with being on call one in two: you miss half the good cases.” It reflected a culture in which exhaustion, self-denial, and total immersion were often treated as signs of commitment.
Combined with the typical Type A, perfectionistic, and sometimes obsessive personality of many medical students and residents, that culture had serious consequences: poor physical and mental health, suicide, the loss or breakdown of intimate relationships, burnout, and widespread dissatisfaction within the profession.
For that reason, I would place much greater and more concrete emphasis on protecting one’s own health and relationships during training. “Take care of yourself” is easy to endorse but difficult to act on unless it is made specific: sleep as much as the schedule permits, eat reasonably well, exercise even if it is only a walk around the hospital, and be cautious about escalating caffeine use. Residents should also be explicitly warned against using prescription stimulants or other substances simply to push through prolonged sleep deprivation.
There is also a potential downside to advising trainees to think through every patient on the way home. Reflection can be valuable, but it can also become rumination and prevent psychological recovery. A brief, deliberate review may help; carrying the entire hospital home every night does not.
Finally, residents should protect the important people and events in their lives. Learning medicine matters enormously, but significant others, family, friendships, and one’s own physical and mental health cannot consistently remain at the bottom of the list. Missing every meaningful event for the sake of training is not proof of dedication. Over time, it is a pathway to burnout, resentment, and dissatisfaction, and may ultimately make someone a less effective physician.
Clean socks help. Sleep, health, boundaries, and sustaining a life outside medicine help considerably more.
After medical school, check to see if they still have a pulse. They must still be human if they are going to learn anything in actual practice, residency
When I was Chief Resident I counselled new interns to avoid making major personal life decisions during what will be the most exciting and stressful year of their lives. Don't marry, divorce, buy a house or have a child if you can possibly put these off for at least one year. The added stress of these types of decisions can be overwhelming in the internship year.
Hi: I need help from people who love science! Can data center cooling loops recycle electricity from condensation as MIT's groundbreaking 2013 experiments suggest?
As data centers face an unprecedented energy and cooling crisis driven by AI infrastructure, billions are being spent on managing thermal phase changes—specifically evaporation and condensation.
In my latest work at Decoding Science, I’ve outlined a simple backyard citizen-scientist experiment that suggests we fundamentally misunderstand electron behavior during these phase changes. Standard solid-state models predict a neutral net current during condensation on these surfaces, but geometric manipulation reveals a measurable electrical anomaly.
If this anomaly scales, it means the massive humidity and condensation loops already running inside data center cooling infrastructure could be harnessed to harvest electricity directly from waste heat. Perhaps equally significant is how understanding evaporation will facilitate the cooling process.
I’ve laid out the simple, reproducible experiment to prove this effect. Would you be interested in a brief look at how rethinking electron kinetics during condensation could impact the future of data center efficiency?
Best regards,
Thomas Alan White
Don’t be afraid to say, “I’m not certain yet.”
Take a good enough history, and many a diagnosis will follow. Don’t forget to do a real physical examination.
Other than the obvious fluid overload conditions, most everyone feels better after IV hydration.
Author, here's some unsolidited help from the spelling fanatic: "Malcolm." Loved the article.
Typo, fixed. Thanks.
Will you fix unsolidited? 🙂
Adam
Funny response. 😀
Great advice!
From a nurse, I really liked #2. I would say to follow that even once you are done residency. Physicians are not out there alone. There is a whole team taking care of that patient - use the team, be a team player.
From a retired physician, remember that it is a privilege to care for another person. Be grateful every day for this blessing to connect with other people and enjoy it. Ultimately the days go by so fast and the next thing you know....you're retired.
I cannot believe it's been 38 years since the start of my internship year! Where did the time go??
Very true. A rewarding journey and very fulfilling, but poof it’s fast.
Great list. I’d add—
Medicine is a craft (not an Art), residency is a time to develop the lifelong habits for learning while having a safety net.
Work-life separation (balance) only leads to discord and mediocre medicine.
Find the joy in medicine, usually first found in small moments
Once you discover the joy, keep having joy, regardless of whether you are on the clock.
I LOVE that replacement of the adage "medicine is an art" with "medicine is a craft"!! My brother is an artist, and he objects when I say "medicine is an art." I will have to change the saying and see what he says!
We've got a bit of a mind meld going...
This may be dated: Never write anything in the notes that would be embarrassing if read in court. Things like "FLK" for funny-looking kid. or "Attractive female, appearing stated age". Keep descriptions accurate, but dry.
"If read in court"! Why use that as your measure? Patients all have access to their own chart notes - most of us never get to court but your patients read your notes. Don't write things that would be insulting, demeaning, misunderstood, etc. May not be as true in small EHR, but Epic notes are read by all. Stay professional!
Decades ago. before we had all these useless things like vaccines to prevent meningitis and before ER was taken seriously (I was told to do a 2nd residency because this ER thing would never work out.) I worked with a pediatrician who was not very doctorly/dignified. His notes (Objective) would start, in this case, with "Alert child, running about the room. Mom and I had to corral him When on the exam table, we had to retrieve the exam table paper from his mouth; no harm done." When subsequently sued for missing meningitis, the plaintiff "expert", having expounded on how desperately sick these children are and how, if they had just sought him out, the child would now be a Rhodes scholar, was asked to read aloud the contemporaneous chart entry. He folded.
I still follow this lead, charting a salient observation or 2.
I belong to another time and come from a culture known for its colorful language. My residents (and patients) like my notes because they succinctly capture the issue in a way you can remember. And don’t worry about the lawyers. I’ve defeated the best of them. All you have to do is look the jurors in The eye and expound. They love to be talked to like fellow humans.
Never read an Epic note that really informed you about that patient that day. My favorite Epic note was at a follow up visit for a rash. It was from the week before and was six pages of Epic babble and the diagnosis was “rash.” I asked the patient to show me the rash. The six pages Epic note was updated with one word—shingles.
I still think the "never put anything in the notes that would be embarrassing if read in court" still holds in almost the inverse fashion - if you document, say, "2+ dorsalis pedis pulses" in an amputee, "good judgment" in a comatose patient, or "no rashes" in a guy with cellulitis, that is embarrassing.
If you "document" false or invalid information, I think it calls into question the validity of the entire note! Unfortunately, it is a side effect of the charting requirements and habits that have been at play over the past 10 years. Most notes are copy/past, templated garbage or fluff. Most of the time, I'm wildly scanning for any tidbit of truth, assessment, guidance.
Cut or copy and paste, templates, order sets, use them at your own discretion.
Templates are great, but in my experience, interns are not ready for them. My advice is to treat templstes like a privilege once ypu have mastered the art of the SOAP note. This appears to be a dying art, due to the ubiquitous use of templates, which are rarely accurately and completely updated to match the patient situation, especially by new physicians and practitioners.
I fear nowadays almost the opposite is true. All the notes are auto-generated templates, 99% filler. I would almost challenge the opposite - "include at least one detail in the history or physical that demonstrates that either you or the patient (or both!) are actually human."
But, yeah, that can get dicey if you lack prudence. :-)
Ok, so the hyperlink under bullet point ten is gold. Well-played. *tips cap*
kkk... I looked at it after your comment... Very Good!