Advice for the New Intern 2.0

A few years ago, I put a pithy slide up on twitter. The slide was meant for new medical student graduates about to start residency. I came up with this list after 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​

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

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

4.     Reflect on the practice of doctors who have earned your respect​

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

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​

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

8.     Care for your colleagues​

9.     Post call, put on clean socks

Twitter being twitter, I got some grief about the list.

“You know the whole 10,000 hours thing is bullocks, don’t you?”

“Don’t think about your patients on the way home. You need to take a break!”

Whatever.

Having just finished my 25^th straight July attending on our inpatient service, I was reminded just how hard it is to be an intern. I thought it was time to update this with some advice that is a bit less pithy, more parochial, but maybe also useful. 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 will learn doing and your will be too tired to read. If you try to read, you will fall asleep and become anxious that you should be studying.

That is all true and pretty good advice but 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 if 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 or caused another doctor to admit the patient? Remind yourself of this fact 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 than 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 diuretics and antihypertensives. You will transfuse blood. Think about the effects these interventions will have. 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 she is 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.[i] If a patient has abdominal pain and you think you need a CT scan, ask yourself what you are 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.

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 and what other diagnoses – especially life threatening ones -- remain possible?

5.     Don’t abandon your common sense (or work to acquire it 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 common ways, the law of parsimony exists for a reason, if someone gets sick a month after surgery, it is probably because of the surgery.

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.

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[i] A clinical reasoning sin on the “Diagnostic Reasoning Yellow Card”