Advice for Internship: Part II

From the archive as a follow-up to last week's post

Last week, I expanded on my nine pieces of “Advice for Internship.” As I noted, a little over a year ago I updated this list after an inpatient attending block during which I was reminded just how hard it is to be an intern. Part II is a bit less pithy, more parochial, but maybe more useful than Part I. The advice might be a bit internal medicine oriented, but I do think it is broadly applicable.

1. Be proactive

Interns are usually told: “Your job is to do, not think. You learn by doing. As the year goes on you will find yourself thinking more and more. Don’t worry about reading. You are going to be too tired to read. If you try to read, you will fall asleep and wake up anxious that you’re not learning.”

That is all true and pretty good advice. However, you can learn more while doing if your practice is deliberate. Deliberate practice during internship is probably even more important today than it was in the days before duty hour restrictions and admission caps. To force deliberate practice, concentrate on being proactive. This forces you to think for yourself.

Being proactive is not easy. Here are some tricks I have found that force doctors, from first month interns to grizzled attendings, to be proactive.

Ask yourself, Why did this patient get admitted? What led him or her to the hospital? What led another doctor to admit the patient? Remind yourself why the patient is in the hospital every day. Whatever else goes on in the hospital, this is a problem that needs to be addressed, if not solved, prior to discharge. Ask yourself what you are doing to solve the problem that led to (or have crept up since) admission.

Each day, create a series of if/then statements for the next day.

If his dyspnea is better, then I will change the furosemide from IV to PO.

If he is still having a fever then I will repeat the chest X-ray.

If her pain is not better then I will begin a PCA.

2. Gamify your learning

The best teachers make learning fun. Do this with patient care. It may seem impossibly nerdy but I love to predict lab results. Every day, you will make changes in a patient’s management. You will start and stop antibiotics. You will add a diuretic or an antihypertensive. You will transfuse packed red cells. Think about the effect of these interventions. Start easy. “I gave 2 unit of PRBC to this non-bleeding patient, how much will their hemoglobin rise?” Work up to more complex. “I added an ARB and a thiazide to this patient with heart failure who I have been diuresing with a loop diuretic. What will each value in his BMP and his calcium be tomorrow?”

3. Work on your differential diagnosis by being your own worst attending

Some attendings will grill you with questions. Most, these days, will not. Ask yourself the questions you need to be able to answer. Every differential diagnosis has a differential diagnosis. Make yourself work this to the 3^rd order. If your patient presents with new onset atrial fibrillation, ask “why is she in afib?” If you determine it is from heart failure, what caused the heart failure? If the heart failure is ischemic, why does she have coronary disease?

4. Work on your clinical reasoning skills by being your own worst attending

Ask yourself the questions you least want to answer. There is almost no decision in medicine that cannot be questioned. For any test you order, what is the diagnostic hypothesis you are testing? Answering this question, you will protect you from suggesting an evaluation without a differential diagnosis.¹ If a patient has abdominal pain and you think you need a CT scan, ask yourself, “what am I looking for?” This seems obvious but it is less and less common these days. This approach will also protect you from chasing down hundreds of incidental findings.

Ask yourself, “what is the pre-test probability of the disease I am testing for?” If it is 90%, do you need the test? If it is 90%, and the test is negative, what comes next?

Also, question every statement you make. Most of our pronouncements are uncertain. When you make a diagnosis, point out to yourself the weaknesses in your reasoning. What data have you discounted to make your diagnosis work? What other diagnoses – especially life threatening ones -- remain possible?

5. Don’t abandon your common sense (or work to acquire common sense if you don’t already have it).

What’s common is common. Common problems are more likely to present in uncommon ways than uncommon problems are to present in a textbook fashion. The law of parsimony exists for a reason. If someone gets sick a month after surgery, it is probably because of the surgery (Sutton’s Law).

6. You were accepted to medical school not only because you are smart but because you have a lot else to offer.

For the last four years you have had to put these traits aside while you (hopefully) immersed yourself in mastering medicine. Begin to nurture your unique (even idiosyncratic) qualities. Use your empathy, your humor, your skills of observation, your dedication to healthcare equity, your ability to function with little sleep, for the good of your patients.

1. A clinical reasoning sin on the “Diagnostic Reasoning Yellow Card.”

Photo Credit: Stacey Koenitz