Sohil Patel, MD

Disclosures

February 19, 2009

Question

I am starting my residency soon, and I am worried about being prepared. What resources should I bring to the hospital? How will I know what to do when I'm alone during night call?

Response

Sohil H. Patel, MD
Sohil H. Patel, MD, Resident, St. Vincent's Hospital, New York, New York

Beginning your intern year is daunting. I know of few other times when one's level of responsibility changes as dramatically as when a medical student becomes an intern. In some respects, the transition requires an understanding that the first time through many new experiences, you may be slow and you may make mistakes. There are certainly ways to minimize such mistakes and, most importantly, to learn from them so that they are not repeated.

As a subintern, I lumbered around in my short white coat with pockets brimming full of "survival guides," including my personal digital assistant, a pharmacopoeia, my stethoscope, a reflex hammer, various scraps of paper and notecards with illegible notes and phone numbers, and maybe a flattened granola bar or two. Early in my subinternship, I was called to see a patient with abdominal pain and lower gastrointestinal (GI) bleeding.

My thoughts immediately became as scattered as the contents of my white coat. In fact, my first 3 thoughts were: Is this an emergency? Should I be worried about colon cancer or angiodysplasia? What are those other causes of lower GI bleeding that I memorized for the boards? As I pondered these deep questions, my resident thankfully arrived and ordered me to check vital signs and do an examination. Only afterward did I look through the various resources in my white coat and find at least 3 resources with the same algorithm for dealing with GI bleeds.

So, my first piece of advice is: know what's in your white coat!

If you buy a survival guide (and I recommend the Washington University series), read through it before you put it in your white coat. Use only 1 survival guide, and become very familiar with it. Likewise, use either a personal digital assistant or a pharmacopoeia or an online pharmacology Website (if your hospital has enough computers), and learn how to use whichever resource you choose.

I also found it helpful to carry a few blank note cards. Every day, I jotted down important phone numbers, or room codes, or simple instructions on how to get things done in the hospital. My notes were a mess, so each night I would rewrite them neatly on a new note card.

Other white coat essentials include a stethoscope, a (functioning) pen light, a prescription pad, your sign-out, and at least 2 black ink pens. For internal medicine, the Mass General Pocket Medicine book is an excellent resource. If you can fit a snack somewhere in your pockets, that always comes in handy.

Recognize Emergencies

This is probably the most important skill learned during intern year. When a nurse calls you about a patient, particularly early in your intern year, you should try your best to always see the patient. See for yourself what types of calls and complaints are emergent and which are non-emergent.

When you see a patient, the best way to determine whether the problem is an emergency is to talk to the patient and get a set of vital signs. Then, compare these findings with the patient's baseline findings. These 2 simple steps will provide critical information about a patient's neurological and cardiopulmonary status.

Certain nursing calls and patient complaints will mandate that you see the patient. Chest pain, shortness of breath, acute abdominal pain, hypotension, mental status change, new neurological deficit, GI bleed, and new fever all qualify. Learn which causes and consequences of such complaints are emergent, and direct your history, physical examination, and management accordingly. Thus, if a patient complains of chest pain, your first objective is to rule out a myocardial infarction, pulmonary embolism, or aortic dissection. Only after doing so should you explore whether the chest pain is actually musculoskeletal in nature.

Finally, especially early on, accept a low threshold for calling your senior resident about all suspected emergencies.

Arm Your Brain

The more medicine you know, the more you will enjoy and learn from your experiences as an intern. Unfortunately, the fourth year of medical school is a well-known cause of brain atrophy. Thus, I found it helpful to brush up before starting intern year. Review the most high-yield, commonly encountered diseases in your specialty, and know them well (including presentation, diagnosis, and treatment). You may also benefit from reviewing school textbooks and study aids.

At a minimum, every new intern should know how to read an electrocardiograph, interpret an x-ray, and understand a blood gas result.

Prepare Yourself Mentally

Anxiety naturally accompanies unfamiliar situations, particularly when your decisions will affect someone else's health. Avoid adding more stress whenever possible.

A common stressor is getting yelled at by a superior because you made a mistake. It is important to recognize 2 components to the message.: The first is the yelling, which is mostly a reflection of your senior's (probably somewhat dysfunctional) personality; the more this is ignored, the better. The other component is the actual message, which often contains very useful advice to avoid making the same mistake in the future. This second component deserves your full attention.

Other ways to avoid needless stress are as follows:

  • Try to build a good rapport with the support staff, and never engage in petty arguments with them;
     

  • Know your limits with difficult patients and recruit the help of social workers when needed;
     

  • Build good relationships with other residents;
     

  • Don't be afraid or embarrassed to ask for help from anyone (especially nurses, who are often your best friend on a busy call night); and
     

  • Do not constantly remind yourself how terrible an intern's life is. If you direct your thoughts to your patients and the amount of good you are doing for them, the intern year can be an incredibly rewarding experience.

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