July is Coming

Jun 29 2011 Published by under Medical education, Medicine

July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart.  Every year around this time medical bloggers (among others of course) discuss the "July Phenomenon".  Today's post is not about the "July Phenomenon", something that may exist in some contexts but is likely dwarfed by other problems in medical education.

Rather than re-hash the debate on whether July in the most dangerous month to be in a hospital (it probably isn't), I'd like to give a little advice to newly minted doctors.  The rest of you are welcome to read it too.  This applies mainly to internal medicine, but I'm sure much of it crosses over into other specialties.

  1. Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  And remember that your senior resident and attending physician are there to help you, whether they act like it or not.  Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.
  2. Listen to the nurses and ancillary staff.  They spend much more time with the patient than you do, they've seen many years of interns come and go.  They can help you, but if they sense you don't respect them or that you aren't caring for their patients well, they will hurt you.  They will do whatever they can to help their patients, and they will not care if they make you miserable in the process.  They will often know more than you do.  If you don't trust what they tell you, verify it.  You do posses a different sort of knowledge, one that you can combine with theirs to help your patients.
  3. Read up on your cases.  You may not have a lot of time for formal reading and studying.  Read up on the diseases your own patient has, and soon you will have an impressive breadth and depth of knowledge.  Listen on rounds, especially when your colleagues are presenting their patients and you'll get more bang for your buck.  Teach the medical students if you have them and you'll learn even more.
  4. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't.
  5. Don't abuse substances other than caffeine.  Even caffeine isn't that good, but if you are susceptible to substance abuse, the stress of internship can be dangerous.  Be honest with yourself, and if you develop a problem, seek help from your program.  You'd be surprised how much help you can get.
  6. Eat well and exercise.  Even if it's only taking the stairs (three down, two up), exercise will help you.  You'll need it.  Try to avoid all the crappy free food at conferences.  Go for the healthy choices at the cafeteria.
  7. Wash your hands.  If a patient asks you if you did, don't be offended.  Thank them for the reminder and do it again.  If you can, wash them in front of the patient so they can see that you care enough to do it.  Remember that certain pathogens, such as C. difficle, sporulate and will not be killed by topical alcohol solutions but must be physically scrubbed off.
  8. Learn to live with uncertainty.  In the hospital you get used to having information at your fingertips.  You can order stat labs, get X-rays and other studies quickly.  You can't do that in the clinic.  Not every patient will present classically.  It is more common for an common disease to present uncommonly than an uncommon disease to present commonly.  Dig?
  9. Trust no one.  Patients will come up from the ER "pre-packaged", work up done, diagnosis made.  Don't believe it.  Verify it for yourself.  Start from the beginning, because leaning on others' workups simply perpetuates errors.
  10. Corollary: examine every patient yourself, and do it right.  The exam can be focused, but do it.  If your resident or student says that the skin is intact, turn the patient over and search for bed sores.  Listen to the lungs.  Check the mouth for thrush.  Be confident in your skills, skills which will improve every day as you use them.
  11. Senior residents, remember the interns are the interns, not you.  Let them do their work.  Let them answer their own questions.  While they are pre-rounding, do your own pre-rounding, checking labs, checking in on patients.  This way, when you pimp the intern on Mr. Smith's potassium and she doesn't know it, your team will realize that not only are you on top of things, but you're watching them,  both to help and to make sure they stay on task.
  12. Wikipedia is not a valid medical reference. I'm sorry I have to even say this.
  13. Ars longa vita brevis.  Enjoy the art.  Medicine is interesting.  It's fun.  And there are no bad patients.  It's just as important to learn how to manage a drug-seeking sociopath as it is to treat an acute MI.  There is always something to learn, even if that "something" is that you don't want to be a gerontologist.

OK, folks.  Go for it.



13 responses so far

  • StThomas says:

    In Britain, it's called the Killing Season.

  • SurgPA says:

    This actually does apply more broadly than just internal medicine. As a PA preceptor, I send my students a letter before their rotation outlining (albeit much less eloquently) several of your points. I am particularly glad to see #2; nurses have saved my butt more times than I can count. To #12, I'm sorry to have to add "neither is Google."

  • rcs says:

    Maybe this is too obvious, but also remind new interns that patients are not just cases, but are people first.

    This isn't a criticism, but while working in a teaching hospital I sometimes saw that young interns became so focused on the injury or illness that they forget there is a person attached.

    Just saying "Good Morning" to a patient before you become engrossed in an exam helps the patient feel more human in an often dehumanizing situation. Directly telling the patient that you need to recheck a procedure they just underwent (such as checking for bedsores) can make them more cooperative rather than complaining about the duplication.

  • J says:

    I worked in a hospital kitchen and I always assumed that December/early January was the most dangerous time because that's when our patient counts spiked. The summer is comparatively slow.

  • Jason Monroe says:

    And remember every mistake is a learning experience. Try to learn from it, don't dwell on it...

    PalMD, I was also thinking of adding you guys to my blogroll at "Medical Noise". Is their any particular way you would like your link to read?


  • Corey says:

    Also, ALWAYS call your consultants. Simple professional courtesy.

  • Very nice post, holmes!

    And while Wikipedia is not a valid source of medical information, I have been told by physicians at my medical school that E-Medicine *is* a very excellent source of reliable medical information, and that it is appropriate to recommend it to our students. Do you agree?


  • Uncle Glenny says:

    I'll vouch for the "trust no one" item. I've had two instances where between admission and diagnosis the reason for entry got garbled:

    The first was for occasional problems swallowing - food would get painfully stuck and I'd have to drink something to (even more painfully) dislodge it. This was a scheduled diagnostic (made via my regular GP). The ?radiologists? told me they found no blockage, even though I'd seen it in realtime while drinking that contrast yuk. Fortunately my internist reviewed things and told me it was a hiatal hernia (what is called, according to wiki, a sliding one). (I have a serious but well-balanced double-major scoliosis, lots of rib rotation, so my innards are over the place and my lung capacity is greatly reduced.)

    The second was little "blips" in my heartbeat, over an xmas vacation visiting my father and stepmother (meeting her for the first time). Lots of stress from work, and that visit (and feeling trapped because of the holiday). After dinner at a place of my stepmother's choosing - very western, with two-stepping, and the sort of place I imagined they beat up people like me in the parking lot - it got really bad. And I was on antibiotics that came with a warning to seek medical attention for "irregular heartbeat." Of course they were talking about anaphylactic shock, but I didn't know that. I went into full panic attack, and off to the ER we went.

    Between admission and getting wired up, apparently my complaint of "irregular heartbeat" had been recorded as "chest pain," of which I had none. I was told nothing was wrong even though I kept pointing at the CRT when I felt one and saying "There!" It's possible there was some bias there too, as this hospital (at least the ER) seemed deserted, I suppose a new hospital for an upcoming retirement community near Phoenix, and the antibiotics were for an infected nipple piercing.

    They were premature atrial contractions. They faded away over the order of months and pretty much never recurred, and didn't affect my exercise (I was a pretty serious bike commuter at the time).

    Both of these were roughly 2 decades ago.

  • Shira says:

    These transfer nicely to vet med, too. Over the next few months my workplace gets our summer interns and vet students. Most work incredibly hard, appreciate the support of the nursing staff, and really try to get the most out of the opportunity. I personally enjoy the opportunity, as a floor nurse, to work with the interns and students. They're driven to learn as much as possible, as quickly as possible, and happy to help with anything from rads, to getting a blood pressure on a cranky cat, to hunting down some warm blankets. The hours are usually long, and the amount of information they are expected recall, study and retain is immense.

    At my workplace, you can usually tell how much the intern/student is loved, by how many baked goods appear during their last week. The more baked goods, the more they will be missed. In fact, I'll be baking a chocolate ganache tart for one of the current students next month (they'll be returning to vet school) for the autumn.

  • mxh says:

    Thanks for the advice. I've just started my intern year and I already know how valuable tips #1 and 2 are.