USMLE Guideline

For all future Internal Medicine rockstars, here are my 2 cents for rocking your residency! (Warning: Looong post :) )

1) ASK! ASK! ASK questions! You're not expected to know everything, and it's your seniors' job to teach you. Don't worry about feeling stupid - most if not all of your intern colleagues feel the same way that you do (and are as afraid as you are!)

2) On the first day of any rotation, ask your senior resident and your attending if they have any specific expectations for you - should you have your notes ready before rounds, etc.

3) Never let another doctor perform a procedure on your patient that you should be learning to do. By that, I mean that while it's okay to let nurses draw venous blood/start IVs in most circumstances, you should be doing your own ABGs, arterial lines, CVCs, paras/thoras, LPs whenever possible.

4) To that end, be the most accountable person on the team for your patient. You should know everything about your patient. Be the person that is the primary communicator - do not cede that responsibility to your senior resident. Give the patient/family frequent updates, including bad news. Learn how to lead a family meeting, and lead your own family meetings as soon as you are comfortable.

5) DO YOUR OWN MED RECONCILLIATION. DO YOUR OWN CHART REVIEW. DON'T BE AFRAID TO GO BACK INTO THE ROOM AFTER YOUR INITIAL ENCOUNTER TO ASK MORE QUESTIONS.

6) Ask for feedback everywhere. I still ask all of my attendings, interns, and medical students for feedback in the middle and at the end of rotations. After every code that I run, I ask the patient's nurse where I could have improved.

7) When you are in the position to give feedback, give honest (but calm and non-emotional) feedback.

8) Remember that everyone else in the hospital is at least as stressed out as you are. Communicate well, never yell. When you are frustrated with a patient, try to remember that you aren't the person in the bed, and that they may be adjusting to a new normal themselves. Decisions during critical times aren't easy for you to make, and you have the benefit of education and mentorship. Your patients do not, and will need lots of information and guidance to help them through their hospital course.

9) Read every night (except for your day off). It doesn't have to be much. During intern year, I did 20 minutes a day from the Washington Manual about at least one patient that we admitted during that day. If you build it into your routine, you won't resent it, and you will be amazed at how much you learn just from a little bit every day.

10) Start discharge planning as soon as the patient gets to the hospital. Be thinking every day about what is keeping the patient in the hospital. Learn the discharge procedures for your hospital.

11) Take time the night before you start a new rotation to look up all of your new patients, do your own chart review, and build a new signout. This helps you look like a rockstar on the first day of the rotation.

12) Avoid the temptation to copy/paste your notes every day. Things get missed even when you are really careful, and there is a very real chance that harm can come to your patients.

13) And, as a future fellow, make sure that all of your consults have a real clinical question. Be specific!

14) If you don't know how to work something up, and you can't find anything in the literature (or UpToDate, if that's your thing), it's okay to call and ask where you should be focusing your efforts.

15) One piece of paper every day: it has your patient list, vitals/labs/etc and your to do list. Write everything your senior resident and attending tell you to do on it. Keep it in the same pocket of your coat every day.

16) Have courage and be kind. To students, to nurses, to patients and to yourself. That's a taller order than you imagine right now. I REPEAT-Be NICE to the nurses. It's an oldie, but that's because it's a goodie. Nurses are the difference between making your job easy and making you want to tear your hair out every single day. Even if you disagree with them, be civil and at least consider what they say - your first on call is not the right time to be talking back to nurses who have 20 years' experience on you. You should still have an expectation that they do their jobs, but if they don't, there's a difference between feeding it back nicely and being a dick about it.

17) Document EVERYTHING!

18) A main priority when you start wearing that long coat, in my opinion, should be doggedly increasing your hospital and medical literacy. What I mean by this is that you know enough medicine right now that everything you look up shouldn't be strictly medical. What will make you more comfortable and effective is learning what all the things are that you encounter that you don't know. For example, learn how things get done at your hospital. Who's the case manager? Who does discharge planning? Where do you have to go in the bowels of the hospital to find some obscure medical device that will get your patient home? Additionally, for surgical patients (and for any patient, really), learn what all the lines and tubes are that could possibly go into or come out of a patient. Do you know enough about central access and the types and lines? Do you know how to tell a PICC from a temporary dialysis catheter? Do you know enough about JP drains to educate the nurse on the non-surgical floor who winds up with your post-op patient? What's an accordian drain? How do you change a VAC? What's the difference between Kerlix gauze and 4x4s? You get the idea. None of these things are taught in medical school yet they are the foundations of patient care. They will literally touch every patient of yours every day. And you need to know what they are. Every time you see or hear something you don't know for the first few months, write it down and look it up.

19) Show initiative. When presenting in rounds, have a differential ready for why your patient is exhibiting the symptoms they are having that morning. If you think a patient might need something that wasn't mentioned by your seniors, bring it forward. Ask to do procedures, fight to do procedures. Sit in the front in noon conference and morning reports. Volunteer to give presentations.

20) Have the hospital protocols at hand (e.g for heparin drips, dvt pphx, massive blood transfusion, etc).

21) Don't let someone else's anxieties/negative energy transfer to you. That senior resident of yours had a terrible case and is angry and worked up? Don't join them. The nurse who calls you freaking out about a patient? Don't freak out...go see the patient and decide for yourself. There's enough negative energy in any hospital to drive any normal person insane. The more you're able to keep calm and manage your own emotions and mental state, the better.

22) Find your hiding spots. You'll feel like you never have a chance to slow down for the first few months but eventually you'll get there. When you have downtime, don't spend it where other people can see you. Find a place where you can hide, answer pages, make some calls, and space out on your phone for a while if you need to recharge. A resident who's unseen but getting everything accomplished is a great resident. A resident who's seen sitting around playing on their phone in the call room is lazy. The reputation you get as an intern will follow you so guard it carefully.

23) Sleep whenever you get the chance to do so. Sleep is your friend. Getting a good night's sleep should be your top priority when you're not at work. If you have to miss a few extra drinks with your friends, so be it. When you are at work, if you're in a place/rotation that expects 24/36hr shifts, short cat-naps are a life-saver if you get the chance.

24) And last, KNOW YOUR PATIENTS. Every job you do will be easier if you know your patients well. Your colleagues/seniors will respect you, the nurses will love you because they won't have to constantly remind you about their problems, and the patients will adore you because they'll feel like they're being listened to.

The learning curve is very steep and in no to time, you'll be surprised how much you've learned.

And most importantly, ENJOY THE CRAP OUT OF IT. Not everyone has the privilege to do what we do, let alone in countries that have everything available and you have the liberty to practice good medicine without worrying about resources. It's gonna be overwhelming at times, exhausting and draining but it's the best years ever and you'll experience more growth as a doctor and as a person than ever!

Go and show them what we IMG's are capable of!! Good luck :) :)