Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Internship or PGY-1

After graduation was complete and I had finished filling out all of those thank-you notes for presents and good thoughts, I turned my attention to making preparations for my move to my residency location. Over my four years of medical school, I had accumulated loads of books and papers. The first thing that I did was toss out any papers that would not be helpful to my little sibs back at medical school. The next thing I did was get rid of the rest of my books and USMLE Prep materials. My little sibs split the lot of them.

We started packing on a small scale but quickly realized that we still had too much “junk”. I even had boxes of things that I had accumulated and had left unpacked for my previous move that had taken place at the beginning of my third year of medical school. I had moved to be located closer to the clinical affiliated hospitals to shorten my commute. A forty-five minute commute was OK for medical school because I could study on the subway but I wanted to spend no more than 20 minutes if I was going to drive.

I made a couple of trips to the location of my residency. I took one of my best friends so that we could scout out some great places to live. She helped me pick out a wonderful three-bedroom home that was located in a wooded area with plenty of jogging and bike trails. Since I have a couple of dogs, I wanted a spot where they could get some exercise and I could get outside. I found the perfect place and I loved living about 1,000 feet from a beautiful lake with woods and streams all around.

After the move, I had one day to get to orientation. I was still in the midst to unpacking on orientation day. I had completed my criminal background check and drug testing. I had also finished completing the materials for my license and smooth move to the local medical society. Orientation started early with mugs of strong coffee and plenty of folks who looked as scared as I was. We received our pagers, our lab coats and our directories. The second day of orientation is where we received our departmental information including our rotation schedule.

I started with Vascular Surgery. These patients are among the sickest in the hospital. I quickly got into the routine of rounding in the early morning (0400h), getting my notes written and then getting ready for rounding with the team. The team, which consisted of the fellows, the surgical chief resident, a mid-level resident, two interns and four medical students would then round. It was the duty of the interns to write every order and plan after we presented our pre-round findings to the fellow and chief.

The residents and students would head off to the operating room while the interns would get orders and discharges done. We would follow up on all labs and studies and then get the discharges completed. I quickly learned to “pre-discharge”, get the orders ready and then make one click to send them to the computer. The computer would print all instructions and prescriptions for me to sign. My dictations would be done at that time too.

Once the daily ward work was underway, one of us would try to get some OR cases while the other intern waited for new admissions and post-ops back from the OR. We would also follow up on all information that came from consultants and all studies as the patients returned. When the patients came back from the OR, it was my job to get them settled in and follow up on what had taken place during surgery. I would look at the OR reports, anesthesia notes and any history and physical information. I would also start a note sheet for tomorrow’s note and check all orders.

By the evening, the fellow would leave and I would report all studies and findings to the chief resident. He or she would add orders or give me the plans for the next day. If anyone was headed for surgery, they would need to have preoperative orders placed for things like nothing by mouth after midnight. Periodically during the day, I would visit each room and find out how the patient was getting along. I would also do things like debride (clean off dead tissue) wounds and follow vital signs and labs. If I was not on call, I would leave the hospital around 6pm after reporting to the on-call intern. If I was on-call, I would receive report from the services that I covered.

I had the unique opportunity of covering cardiac, thoracic and vascular when I was on call. The other interns only covered one other service and their own. At first, the cardiac patients were scary but later, I fell into taking care of them just as I took care of my own vascular patients. My patients were the sickest patients on the three services and I knew them best.

After vascular, I rotated as intern through surgical oncology and colo-rectal surgery. My program director was very impressed with my work so he decided to change my schedule to include a month as Surgical Intensive Care Unit resident. Usually, this rotation would go to a second year resident but a couple of interns managed to get this rotation. I was fortunate because the other two residents on this rotation with me were second year anesthesia residents. They taught me how to place internal jugular central lines and to float Swan-Ganz catheters. The nephrology fellow taught me to place temporary hemodialysis catheters and how to calculate fluid balance. I already know loads about mechanical ventilation but I learned even more from the critical care specialists. It was a great month for me.

I was then invited to spend a couple of months at the Veterans hospital. This was an away rotation that was totally awesome because there was so much operative experience. I honed my surgical skills and could hold my own in the ICU. My chief resident was very comfortable with my work and left me in charge of the service (as an intern no less) when he needed to go out of town. At first, it was scary but I learned that I could trust my instincts. My attending physicians were great teachers and things hummed along for me.

I went through another rotation on Vascular and then Thoracic. I made a deal with the other interns in that I would do all of the dictations and discharges if they would pull chest tubes and work out discharge planning. They hated to dictate and I had become very efficient at getting these things taken care of thanks to the VA hospital. My fellows were great to work with also. I was very comfortable calling them at home and updating. One of the most demanding fellows turned out to be one of my best teachers. He showed me how to sew down grafts.

I finished my year as Night Float intern. I covered all of the General surgery patients. There was an intern for Trauma who took care of the Trauma patients and did all admissions. If he or she was busy, I would admit patients and follow up on studies. I learned to anticipate problems and get them taken care of. I also learned to do make things happen that needed to happen. I made great friends with the night radiography technicians who would get studies completed for me and placed in front of the radiologists before I could get down to the department. They were great folks to work with.

As I headed into second year, I knew that second year would be my worst year. As a more senior resident, I would expected to play bigger role in keeping the service running. Since I would still somewhat junior, I still had a huge learning curve too. All in all, my intern year was great. Some of my chief residents and fellows were very difficult to work with but I always stepped up to the plate and got the job done.

Being a good intern is being anal about every detail of your patient’s care. It took a few months to learn the “ins and outs” of good patient care but I took careful notes and operated every chance that I could. The nursing staff also gave me high marks for getting things done and keeping the services under control. The hours are long and sometimes the work seemed endless but there was a learning point to every task. Intern year went quickly but I felt in control of my learning.

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6 January, 2007 - Posted by | intern, surgery, vascular surgery

2 Comments »

  1. Hi Drnjbmd,

    I am about to start the intern year of my General Surgery residency, and found your posts to be very helpful. One of the last thoughts you left the reader with in this entry was how you felt in control of your learning. That is a goal I strive for, and I wonder how you would advise an incoming intern to prioritize their learning. What would you advise as top objectives for the surgical intern, and as far as reading after a day of work – should we focus on textbook or journal or a mix at this point? How did you approach intern year, and figure out what to focus on first? My program is doing an excellent job during these weeks of orientation to guide us in the right direction team-wise; I just wanted some insight on personal goals I should have for self-directed learning, and how to become the best intern I can be.

    Thank you for reading this through, I appreciate your posts immensely.

    Comment by M | 20 June, 2013 | Reply

    • To M:
      Figure out how your program is going to help you prepare for ABSITE. Make sure you purchase (if it’s not already provided), the textbook that your program tends to use- Sabiston’s, Greenfield or Swartz, and make it a point to do regular reading. I always made it a point to do a minimum of 30 minutes of meaningful reading per day and 2 hours per day on the weekend (usually less busy). Just start at the beginning of your textbook and read. You will start to figure out when to move toward the things that are more clinically relevant but you have to have a strong basic science foundation (the first chapters in any surgery text). You next step is to make sure that you learn everything about ward care of your patients. This means making sure everything gets done perfectly and timely. I always made sure that I know the “plan” from my chief so that I could keep patients moving along toward discharge. The more you understand how to plan and manage, the more efficient you will become. Why emphasis on efficiency? Because it means that you will get into the OR more-which is golden time as an intern. Watch your attendings and chiefs to learn how to become a solid technical surgeon. You also want to learn every step of the operative procedures that are being done on whatever service you are rotating. If you are on laparoscopic surgery, then know the steps of the laparoscopic procedures so that you can be an excellent assistant (and even perform some of the steps in the case). Ask questions when it is appropriate and make sure your questions are not things that you should know from reading. Treat every patient as a chance to learn something new as your time as an intern will go by very quickly. Your PGY-1 year is truly the one year that you have “carte-Blanche” to get a good foundation in terms of learning. Ask your chief residents how they handled their PGY-1 years as they are your best resources (so are the PYG-2s). Ask your chiefs about journal reading as they will point you in the best direction. Also, watch the presentation styles carefully during Mortality and Morbidity conferences. Listen to the questions that the attending physicians ask and learn how to give a good M & M presentation that provides a learning experience for the audience. Finally, get to know and help your fellow PGY-1 residents well. You are going to be together in some form for a long time, thus you need to learn to rely on each other for fellowship and assistance. Your personal goals should be to: develop a very strong and honest work ethic- never lie or throw a fellow resident/attending “under the bus” because karma will place you in a vulnerable position at some point; respect the rest of the hospital staff (nursing and otherwise) because you are all part of a team- don’t let them tell you how to do your job but respect their opinions and listen; respect the people who are ahead of you on the team (anyone above PGY-1) because they have been in your shoes; don’t gossip with anyone and don’t allow them to waste your valuable time ( when the gossip starts, you can always smile and say that you have a hot date with Dr. Sabiston, Greenfield or Schwartz in the call room as a joke and go get your reading done, computer work or research done) and finally, learn to learn and work when you are tired and cranky because that is when mistakes happen. The system doesn’t care about you personally so you have to first care about yourself, your sanity and your patients, even when you don’t like the exhausted feelings that you are having. The patients are not there by choice and on some services- trauma for example, they might be a challenge to care for because of circumstance. Again, don’t take this personally but file things under “experience”. (I found a place of sanity on the roof (our hospital was the tallest building around) where I could take a couple of deep breaths of un-HVAC air and relax for 5 minutes. Learn how to organize your thoughts and dictate well- speak more slowly and clearly, spell out names and give numbers clearly. Say “thank-you” at the end of your dictations because it is nice. You may never meet the person who does your transcriptions but you want to be efficient, correct and careful. At first, listen to your dictations to make sure you haven’t missed anything- you can always re-record/edit as long as you haven’t pressed the “send” button. My other thing was that I was always appreciative of housekeeping (didn’t leave the call room messy; trash in the trash can and a special “thank-you” (candy) on holidays. Many times I would enter the “Chief’s Den” and find an extra comforter, pillow or even some left-over flowers that just brightened my day from the housekeeping staff. They are just nice people that did a great job and I appreciated that. Good luck and enjoy the learning.

      Comment by drnjbmd | 20 June, 2013 | Reply


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