Medicine From The Trenches

Experiences from medical school, residency and beyond.

New Intern (the utility of listing and lists)…

I am going to relate some of my practices as a new intern. I certainly learned from the best (my love and infinite respect to J-Ro wherever he is) and have generally kept up with the solid patient care practices that I learn from day one on the job.

Lists

Every good intern needs to have some kind of list procedure and I was no exception. Placing those little square boxes beside things to do and frequently checking my list became the “bane” of my existence on the wards. As a newly minted intern, my principle job was to make sure that every facet of patient care was done and assessed in a timely manner. I developed the practice of carrying both a clipboard (clip kept small pieces of paper from falling out) and blank sheets of paper. I would have a master list of patients that were under my care with Post-It sticky notes for things that I had to add to the lists in a hurry.

Daily Routine

When I first arrived in the morning, I pulled up my patient list and busied myself with checking the latest lab values. I scheduled my hospital arrival time based on service and the number of patients that I had signed out the night before. I knew that I would get at least one or more new patients and thus, on a service that contained a large number of patients with complicated diagnoses (or needs), I arrived earlier and on services with more long-term patients, I could arrive a bit later.

I would list my labs, check any imaging studies from the day before (or the middle of the night) and circle them in red (I always carried a 4-color pen or bright pink highlighter). I would want to make sure that the results and plans from these results were in my notes and orders for the day. Sometimes, lab results and imagining study results would indicate the need to change plans for the patients for the day. This is why these were the first things on my list.

My next tasks were generally to check with the night charge nurse for the things that needed immediate attention. Since the charge nurse knew that I was usually the first on the wards, he/she didn’t have any problems letting me know anything that needed immediate intern attention from overnight. In general, the intern that was covering would also have reported to me but occasionally, there was a slight difference in the reports between these two people. I also make a concerted effort to get sign-out from the covering intern as soon as I could so that they could take care of their own patient load and I could get “cracking” on my daily duties. This is a good characteristic to have.

By the time my chief resident (and fellow on some services) arrived on the floor, I could hand them a patient list with the immediate problems (and my handling of them) circled in red. We could then start morning rounds with me (or a medical student) presenting the patient outside of the door, going inside for a look at the wound/incision, and any additional care options that the chief might want to add. These things were  carefully noted and checked by me as I was responsible for everything aspect of bedside care on the service. A medical student could follow a patient or two but the intern has to be sure that everything is checked, double-checked and done.

Right after rounds

As soon as rounds were finished, I would quickly enter any orders that needed to be entered and head off to the OR for cases that had been assigned to me by the chief resident. Usually, unless there were loads of ward patient care duties, I could get to the operating room to do a case or two. I would check the schedule the night before to make sure that I had done my anatomy and surgical atlas work for any of the PGY-1 level cases. I didn’t want to miss any of the “pimp” questions that I was bound to be asked over the incision during these cases.

If patients were likely to be discharged, I developed the habit of dictating a pre-discharge note that I only had to dictate an addendum to when the patient actually left. This meant that I could enter my discharge orders and scripts, pre-dictate the discharge and then release all of the information and scripts as the patient was leaving the hospital. Since these decisions were made during morning rounds or shortly after discussion with the attending, this turned out to be a great practice but one had to keep good records of patient numbers and what had been pre-written/dictated. There was nothing that prevented me from grabbing an order sheet, writing some discharge orders and keeping those orders on my clipboard (dating them when needed).

I also made it a point to go and observe any studies that were being carried out on my patients whenever possible. There were procedures like gastrografin swallow studies and upper gastrointestinal studies that were great to observe in “real time” along with the radiologist. I also made sure that I reviewed all of the CT Scans, cath reports, angiography studies and other studies of patients that were admitted the night before for surgery. I reviewed as much as possible in terms of their care in clinic and why the decisions had been made to take them to surgery. In short, I wanted to be there and get to the bottom of every patient detail as much as possible. Much of this type of investigation work was done on call based on my notes from clinic.

Do you actually know the most about your patients?

I have to say in all honesty, that my best skill as an intern was to know more about what was happening with my patients than anyone else on the service. Most of the time, the nursing staff would call me when a patient went to radiography so that I could slip over and look at their studies. The radiography techs and transporters were also happy to let me know when they had picked up a patient, especially at night. I always wanted to get in and see for myself, what the studies looked like even if it meant that I would lose some sleep. I knew that I would rest better when I had tracked down my studies; knew the results and had discussed them with the chief that was on call so that any plans could be done.

Sign Out

One of my colleagues replaced my folded paper system with an Excel system that I still use today. On this system, we kept a running log of patients, locations and things to do and check. An intern covering my system could easily check the sign-out sheet (done by printing out Excel sheet) or check our files on the service computer. I always kept this backed up on a jump drive too.

I never signed out anything that I could do or check before leaving. I knew that the night float intern would have a huge patient load ergo, I made sure that all admissions and post-operative checks were done by the time I left. Unless a patient was still in recovery (in which case, I checked on them anyway to fill anticipated needs), I didn’t sign out discharges or new admissions. If I had to stay a bit longer, then I stayed a bit longer (signed out earlier) and updated the night float just as I left the hospital.

There is no substitute for making your own rounds and checks in the late morning between cases, in the afternoon to see that everyone got home OK and just before signing out to the night float (or receiving sign-out if you are on call). It is things that are signed out that are most often missed. On-call folks get busy and emergencies come in that will delay things. In short, I tried not to sign out anything that I could do by phone or that was routine (should have been done earlier in the day).  My regular walking around solo rounds usually kept me on top of things.

Going off service

Another very nice thing that I always accomplished was an “off service” note that summarized the care of a long-term patient. There were many times when a patient (especially a burn patient) had been hospitalized for months. When I received such a patient, I wrote a summary of care up to when I started and a summary of the care while I was on service. If the patient died or was discharged a couple of days after I left the service, my “off service note” would assist the new intern in doing an accurate dictation on that patient. This type of note would also help them get up to speed when they came on too. I always appreciated when someone did this for me and readily returned the favor. An “off-service” note is one of the best things for good continuity of patient care.

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24 December, 2009 - Posted by | first-year, general surgery residency, on-call

5 Comments »

  1. Dear Drnjbmd:

    Hello, I am a recently graduated US med student about to start Intern year. I wrote to you back in 2009 about having failed my first year of medical school. I just wanted to write a quick message to you now to let you know again what a valuable resource your blog entries have been, as well as how much I appreciate the advice you had given me (directly and non-directly by way of comments to other individuals).

    I ended up finishing med school, decided to pursue General Surgery, and matched to my first choice residency for the field I pursued. Intern year will start July 1, and I just recently read the article you wrote about the utility of checklists. Thank you again for putting your thoughts out there for people to learn from — it certainly helped me!

    Comment by M | 10 June, 2013 | Reply

  2. To Nat:

    I don’t have much experience with US citizens going offshore and attempting to return. Most of the folks that I have encountered in that position have been people that we have interviewed for residency. Sad to say, we have had so many more American grads that we matched because they had better credentials and were more suited to our residency program.

    It’s difficult to go offshore and return. Being a US citizen makes the visa issues disappear but you have to have outstanding grades and board scores which may not be easy from overseas. Medical education here is very oriented towards the licensure exams while medical education overseas is often geared toward practice overseas.

    The students who are most successful in getting back into this country are those who have done clerkships here at US hospitals where they can make some connections. If you are currently overseas, I would encourage you to do some rotations/observerships here so that you can get some good letters and evals of your clinical work.

    Needless to say, rock the boards (all steps). Good luck.

    Comment by drnjbmd | 3 March, 2010 | Reply

  3. Thank you for your website! I really enjoy reading it. Have you have done any articles or plan to do any articles in the future about U.S. citizens studying medicine in a foreign medical school but who want to return to the U.S.? Thanks again! 🙂

    Comment by Nat | 27 February, 2010 | Reply

  4. These r the duties that I (as an intern) always have to do.but the thing that I really need to know is how to endure the sleeplessness of emergency or ward shifts(here in Iran our shifts in busy wards is almost 30 hours..and it is so much,also we can rest for 4,5 hours but it’s not enough for me.
    I also have lost my concentration esp for studying , this I don’t know how to over come…

    Comment by z | 21 January, 2010 | Reply

    • To Z:
      When you know that your hours are long, try not to make how tired your are, the focus of you thoughts. When you get a chance, sit down and put your feet higher than your head. I used to sit in a chair and put my feet on the wall to get a good stretch and some good circulation going. Go outside often for a breath of fresh air. You don’t have to stay out there but one or two minutes three or four times per night can make a huge difference. For me, just getting a chance to rest (not necessarily sleep because I never slept but napped at the hospital) seemed to be enough. My shifts as an intern lasted 30 – 48 hours too. I forced myself to read a minimum of 30 minutes daily and 2 hours on any weekend that I was off. I kept check sheets to monitor my progress.

      The next thing you need to do is keep yourself in good physical condition. This means keeping flexible, doing abdominal work (helps with posture) and drinking plenty of water. When you are dehydrated (easy to do inside a building), you tend to feel more exhausted. I made myself drink at least 16 oz of water every hour and kept ice water nearby all of the time. It was better than coffee or tea for me and didn’t make me dehydrated. Since I was a surgical intern and often operated all night, I took great pains to keep myself flexible and hydrated. With more physical activity, I actually felt less tired and stressed.

      Finally, walk flights of steps when you find yourself dragging. You at least get some aerobic conditioning and you get a change of scenery. I made myself walk at least 8 floors (16 flights) up (down doesn’t count) every day when I was working and couldn’t get to the gym. In the gym, I tended to do things like swimming (you are in a nice quiet world in the water) so that I could be alone with my thoughts and plans. This was good for stress relief too.

      Yes, your hours are long but they won’t always be that long. Focus on how the clock is moving and every day that you finish is one less day that you have to finish. Again, if you focus on keeping your environment changing by keeping in motion, you will actually find that the time goes faster. If you focus on how tired you are, you will be more tired. But keep in mind, that clock keeps ticking and time does go by. Good luck!

      Comment by drnjbmd | 22 January, 2010 | Reply


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