What to Expect When You're an Intern

Graham Walker, MD


January 30, 2012


How will things change as I transition from medical student to intern?

Response from Graham Walker, MD
Chief Resident, St. Luke's-Roosevelt Hospital Center, New York, New York

As an intern, you are the primary patient data collector. It's probably the most important part of the team. Welcome to the role.

Your first days as an intern may seem like just another medical school rotation; you're still writing notes, but what you write matters much more now. Your team will rely on you to know your patients and their numbers inside out, so if you say the creatinine is trending down, it better be.

Although your resident and attending are ultimately responsible, you should feel very protective of your patients. No one will know their quirks and details better than you. No one will do a more thorough exam than you, so it's your job to report it if the patient has bounding pulses.

This may feel like a heavy weight on your shoulders -- and it is -- but it's preparation for becoming a junior resident in a year's time. Patient after patient, you'll start to hone your clinical acumen, asking fewer but more important questions, and performing a more focused but relevant physical exam.

Let's take a patient with a headache, for example. The medical school approach is to take a complete history and perform a full physical exam on the patient to generate a differential diagnosis and assessment. In contrast, as the intern, you're expected to use your preset knowledge of headache differentials to make your history and physical relevant. You will weed out questions that are probably less important, like whether or not the patient has pets at home.

Similarly, you probably don't need to do a thorough abdominal or respiratory exam, but you certainly want to know if the patient has had any trauma to the head recently. And you'd remember to ask about that, given that subdural hemorrhages can present after trauma (and cause headaches).

Learning on the Job

Still, you're not expected to know everything, and you're going to occasionally miss things, no matter how thorough you are. That's why you're in residency, and why there's a senior resident and attending to supervise and support you.

In fact, this is one way in which internship is like medical school: You should be asking a lot of questions.

Residency flies by. It's a mix of being supremely busy and changing rotations every month. So now -- as the intern -- is the time to sit down with your resident on a slow call night and ask them to explain that one concept from medical school that you still don't completely get. Sometimes, getting a resident's perspective will help simplify a confusing concept, and it also helps residents become better teachers.

Ask them why they're telling you to change antibiotic coverage, or have them help you practice interpreting ECGs. Ask your attending, too. (That's why we get paid the big bucks!)

Another reason to ask questions is that your goal as an intern is to become that hotshot, smart, confident, respected second- or third-year resident that everyone likes to work with. It won't come easily for everyone with every topic, but the more time you put into intern year, the more you'll get out of your residency and the easier it will become as your responsibilities grow.

Navigating Uncertainty

Speaking of asking, you should know when and how to ask for help. Sometimes it's a simple, "Hey, can you go through this patient's labs with me? I can't figure him out," to your resident. Other times, you'll be faced with patients who are unstable or looking pretty moribund, and you're the first or only person around.

If your Spidey sense goes off* ("This guy doesn't look so good"), go through your ABCs and call for help. The great thing about being at a hospital is that there are many residents. Call your senior resident, a fellow, an attending, or have someone do it for you. Call a rapid response. Call a code.

One of the biggest mistakes interns make is not realizing they're in over their heads. Your resident and team would rather have an occasional false alarm than be 10 minutes behind in the evaluation and resuscitation of a potentially critical patient. Trust me. Your job as an intern is to be sensitive. Specificity comes later.

Internship is a big change, but in some ways it's just an extension and refinement of your medical school training.

As the Spiderman character Uncle Ben says, "With great power comes great responsibility." You've been given an opportunity to make a profound impact in strangers' lives, heal them, and relieve them of pain. Cherish it.

Just don't skip steps or jump to conclusions. Be thorough and systematic (and make sure you get the drug dosages right).

*Part of the point of internship is to develop and hone your Spidey sense.


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