24 December 2009

New Intern Practices (lists and listing)...

I am going to relate some of my practices as a new intern. I certainly learned from the best (my love and infinite respect to J-Ro wherever he is) and have generally kept up with the solid patient care practices that I learn from day one on the job.


Every good intern needs to have some kind of list procedure and I was no exception. Placing those little square boxes beside things to do and frequently checking my list became the "bane" of my existence on the wards. As a newly minted intern, my principle job was to make sure that every facet of patient care was done and assessed in a timely manner. I developed the practice of carrying both a clipboard (clip kept small pieces of paper from falling out) and blank sheets of paper. I would have a master list of patients that were under my care with Post-It sticky notes for things that I had to add to the lists in a hurry.

Daily Routine

When I first arrived in the morning, I pulled up my patient list and busied myself with checking the latest lab values. I scheduled my hospital arrival time based on service and the number of patients that I had signed out the night before. I knew that I would get at least one or more new patients and thus, on a service that contained a large number of patients with complicated diagnoses (or needs), I arrived earlier and on services with more long-term patients, I could arrive a bit later.

I would list my labs, check any imaging studies from the day before (or the middle of the night) and circle them in red (I always carried a 4-color pen or bright pink highlighter). I would want to make sure that the results and plans from these results were in my notes and orders for the day. Sometimes, lab results and imagining study results would indicate the need to change plans for the patients for the day. This is why these were the first things on my list.

My next tasks were generally to check with the night charge nurse for the things that needed immediate attention. Since the charge nurse knew that I was usually the first on the wards, he/she didn't have any problems letting me know anything that needed immediate intern attention from overnight. In general, the intern that was covering would also have reported to me but occasionally, there was a slight difference in the reports between these two people. I also make a concerted effort to get sign-out from the covering intern as soon as I could so that they could take care of their own patient load and I could get "cracking" on my daily duties. This is a good characteristic to have.

By the time my chief resident (and fellow on some services) arrived on the floor, I could hand them a patient list with the immediate problems (and my handling of them) circled in red. We could then start morning rounds with me (or a medical student) presenting the patient outside of the door, going inside for a look at the wound/incision, and any additional care options that the chief might want to add. These things were carefully noted and checked by me as I was responsible for everything aspect of bedside care on the service. A medical student could follow a patient or two but the intern has to be sure that everything is checked, double-checked and done.

Right after rounds

As soon as rounds were finished, I would quickly enter any orders that needed to be entered and head off to the OR for cases that had been assigned to me by the chief resident. Usually, unless there were loads of ward patient care duties, I could get to the operating room to do a case or two. I would check the schedule the night before to make sure that I had done my anatomy and surgical atlas work for any of the PGY-1 level cases. I didn't want to miss any of the "pimp" questions that I was bound to be asked over the incision during these cases.

If patients were likely to be discharged, I developed the habit of dictating a pre-discharge note that I only had to dictate an addendum to when the patient actually left. This meant that I could enter my discharge orders and scripts, pre-dictate the discharge and then release all of the information and scripts as the patient was leaving the hospital. Since these decisions were made during morning rounds or shortly after discussion with the attending, this turned out to be a great practice but one had to keep good records of patient numbers and what had been pre-written/dictated. There was nothing that prevented me from grabbing an order sheet, writing some discharge orders and keeping those orders on my clipboard (dating them when needed).

I also made it a point to go and observe any studies that were being carried out on my patients whenever possible. There were procedures like gastrografin swallow studies and upper gastrointestinal studies that were great to observe in "real time" along with the radiologist. I also made sure that I reviewed all of the CT Scans, cath reports, angiography studies and other studies of patients that were admitted the night before for surgery. I reviewed as much as possible in terms of their care in clinic and why the decisions had been made to take them to surgery. In short, I wanted to be there and get to the bottom of every patient detail as much as possible. Much of this type of investigation work was done on call based on my notes from clinic.

Do you actually know the most about your patients?

I have to say in all honesty, that my best skill as an intern was to know more about what was happening with my patients than anyone else on the service. Most of the time, the nursing staff would call me when a patient went to radiography so that I could slip over and look at their studies. The radiography techs and transporters were also happy to let me know when they had picked up a patient, especially at night. I always wanted to get in and see for myself, what the studies looked like even if it meant that I would lose some sleep. I knew that I would rest better when I had tracked down my studies; knew the results and had discussed them with the chief that was on call so that any plans could be done.

Sign Out

One of my colleagues replaced my folded paper system with an Excel system that I still use today. On this system, we kept a running log of patients, locations and things to do and check. An intern covering my system could easily check the sign-out sheet (done by printing out Excel sheet) or check our files on the service computer. I always kept this backed up on a jump drive too.

I never signed out anything that I could do or check before leaving. I knew that the night float intern would have a huge patient load ergo, I made sure that all admissions and post-operative checks were done by the time I left. Unless a patient was still in recovery (in which case, I checked on them anyway to fill anticipated needs), I didn't sign out discharges or new admissions. If I had to stay a bit longer, then I stayed a bit longer (signed out earlier) and updated the night float just as I left the hospital.

There is no substitute for making your own rounds and checks in the late morning between cases, in the afternoon to see that everyone got home OK and just before signing out to the night float (or receiving sign-out if you are on call). It is things that are signed out that are most often missed. On-call folks get busy and emergencies come in that will delay things. In short, I tried not to sign out anything that I could do by phone or that was routine (should have been done earlier in the day). My regular walking around solo rounds usually kept me on top of things.

Going off service

Another very nice thing that I always accomplished was an "off service" note that summarized the care of a long-term patient. There were many times when a patient (especially a burn patient) had been hospitalized for months. When I received such a patient, I wrote a summary of care up to when I started and a summary of the care while I was on service. If the patient died or was discharged a couple of days after I left the service, my "off service note" would assist the new intern in doing an accurate dictation on that patient. This type of note would also help them get up to speed when they came on too. I always appreciated when someone did this for me and readily returned the favor. An "off-service" note is one of the best things for good continuity of patient care.

21 December 2009

First Semester of Medical School (it's over and done)...

For many people, the first semester of medical school is complete. By today - barring being snowed in and delayed at one of the east coast airports - you are on your way or at home for the holiday break. Many folks worked harder this first semester than in any aspect of their previous academic endeavors only to find that they didn't do as well as they wanted or anticipated. The good news is that the semester is over and the bad news is that you have to go back and face second semester in a few short weeks.

My first piece of advice is to take a bit of time to assess what worked (and didn't work) in terms of getting the material mastered for this past semester. There is little use in anguishing over grades (you get what you get when you get it) or what you "could have done". You put everything regardless of good or bad, behind you and move into the next semester renewed. If you failed, it's behind you until you have to re-mediate. If you passed, it's behind you and you have to move forward. That's one of the great things about medical school in that it carries you along at a relentless pace.

As you take stock of the things that worked well for you, see if there is something that you can do to enhance your efficiency. You are going to have to be more efficient in the upcoming semester and into next year so why not take a look at what you can "tweak" to make better. If you are totally satisfied with your work, still look at adding some activities such as physical conditioning or stress relief. Trust me on this one, stress can come out at any time in medical school no matter how well you are doing. Having some kind of a stress relief plan is a good thing. Even if you walk around the block a couple of times, it will just relieve some of the stress.

Resist the urge to try to study for Boards during this holiday. You NEED rest and relaxation. If you feel that you must do something, then have a cursory look at First Aid for Step I but there is little that you can do that will make any meaningful "dent" in what you will have to review after next year is done. Your best prep now is rest and relaxation. Don't even try to use these next couple of weeks to "read ahead" for the next semester. Work on a plan for increased efficiency but you know that you will have ample time to study for the next semester of coursework.

Take this time to catch up with old college mates who have gone into something besides medical school. I found this practice most fulfilling because they wouldn't allow me to "talk shop" during our get-together. I could hoist a brew or enjoy the holiday lights without feeling compelled to study something or plan to study something. If you were fortunate enough to complete your Gross Anatomy course, relish in the fact that you can burn those formaldehyde-scented scrubs now. See, there is always something to put behind you. If you are not done with Gross Anatomy, well, you are at least further along that when you started.

I also used the holiday break to catch up on some of the latest movies, non-medical reading and other nice non-medical pursuits. Even today, as I have completed submitting grades and evaluations for the students that I teach, I am contemplating the movies that I will catch up on this week. I have some holiday clinical duties but as I have posted in past posts, I actually enjoy the hospital during the holidays. The patients are grateful that you are working in addition to the wonderful decorations everywhere. I love to take a couple of minutes to sniff the branches of the huge lobby Christmas tree just to get that holiday feeling. I also enjoy hearing the Christmas carolers strolling the halls to serenade the few patients who are left in the hospital.

In short, take the time to enjoy your time with your family and friends, to celebrate that you have gotten through your first semester and to face the upcoming semester with some anticipation. Try to remember that this whole "medical school thing" is a process and not a commentary on your worth as a human being. My bet is that you are far more complicated than your studies.

If you didn't get the grades you wanted or feel that everything you have learned has "leaked out of your brain" relax because that hasn't happened. You definitely know more than you think you know. Every medical student feels that they are forgetting everything that they have learned. You may not remember every tiny detail but the neural pattern is there and can be recovered with a bit of review. In short, relax, that knowledge is in there and will be there for you. Next semester will build upon what you went through this semester but isn't dependent upon you having done a "perfect" job with this semester's material. You will have another shot at anything presented this semester next year and for Step I study. Again, this is why you can relax right now.

Finally, to those who may have to re-mediate, put off the self-flagellation. You have learned what not to do so concentrate on thinking about what you will do differently. Assess what worked and resolve to hone that what worked for you. Don't be ashamed and don't keep running thoughts around in your mind that you have closed any doors to having a fine medical career. You haven't closed off anything. Remember that the vast majority of medical students will have something to face in the future that will cause a hiccup or a step-back. If you had your hiccup now, you are done. Put it behind you and know that you are going to move forward to enjoy a great career.

Happy Holidays!!!!!