Transcript How To Be a Good Intern by S. Rinner, MD

How to be a good intern
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AKA:
PGY-1
 R-1
 Wedge
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Why be a doctor? An opportunity to
participate in the center of the
human drama:
Life and death, not life on the periphery
Growing up medically:
Internship is the seminal year of
your career
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You will work harder (I hope)
You will learn more
You will acquire more responsibility
You will form work habits for a lifetime- good
or bad
Mandated intern hours:
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“The lines Mundy previously mistook for life
experience are the lines of an overindulged child who
has never been beaten up by anybody’s police or
crossed bad borders, or been locked away in the White
Hotel or hog-tied and chained to the floor of a
helicopter. In this respect he embodies what Mundy
considers the least attractive characteristic of both our
Western leaders and their spokesmen: a levitational
self-belief that nimbly transcends the realities of
human suffering.” John Le Carre: ABSOLUTE
FRIENDS
The rule makers may not always get the picture.
Mandated intern hours:
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However misguided we may find these rules, they are
the rules and must be followed.
“I’m not going to be one of those people who gets old
and says ‘I wish I had done this. I wish I had done
that.’ Every once in a while, you’ve got to do
something hard, do something you’re not comfortable
with. A person needs a gut check.” U.S.Marine,
Fallujah, DMN 11/21/04
Regardless of the rules, this is your year to do
something hard.
Internship: 1967
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Every other night on call.
½ dozen antibiotics
½ dozen cardiac drugs
Very limited radiology
Interns do much lab work, draw blood, start iv’s,
pass NG tubes, foleys, etc.
Wages $5100
Interns bitch a lot
Internship: 2
2006
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Every 4th night, off at 1330, limited hours.
Dozens of antibiotics.
Dozens of cardiac drugs.
Numerous, complex imaging techniques.
Interns write lots of orders.
Interns uncertain as to location of veins.
Interns uncertain as to location of lab.
Invasive radiologists do lots of procedures.
Wages $35,000+.
Interns bitch a lot.
The difference:
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1967: Learning by passive absorption
2006: Learning by active transport.
You will have (relatively) a great deal of free
time; how you use it will have a major impact
on your skills as a physician.
Learning:
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Look things up:
1967: The Index Medicus (tedious)
 2006: Pubmed, Uptodate, etc., etc. (easy)
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Look things up:
1967: Later
 2006: Real time (like now)
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A compassionate physician who is inept is still
inept.
Don’t operate on hearsay. You have to read.
Skills vs. Knowledge
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Skills: increasingly demanding of our time and
intellectual capital; and a source of mental clutter?
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Finding the cafeteria, where to park, etc.
Learning to use the computer system, your PDA, and filling
out numerous forms.
Algorithms.
Your brain as an automatic transmission.
Knowledge: using your brain for what it was designed.
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Thinking about what you are doing.
Making decisions based on thinking.
Your brain as a manual transmission.
Distractions:
“According to a 2005 British study commissioned by
Hewlett Packard, workers who constantly interrupt
tasks in order to respond to e-mail, text messages and
phone calls suffer a 10-point drop in I.Q. following the
distractions. That’s more than double the drop in I.Q.
experienced by marijuana smoke.”
DMN, 05/29/06
Learn to focus amid the chaos.
“You frag ‘em, we bag ‘em.”
Motto on a mortuary truck, Vietnam.
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“The burden of harm conveyed by the collective
impact of all of our health care quality problems
is staggering.” U.S. Institute of Medicine Report
Try really hard not to add to the burden of
iatrogenesis.
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“In 1952, penicillin was fully effective against all
strains of staphylococcus bacteria, to such an
extent that by the early 1960s the U.S. surgeon
general, William Stewart, felt confident enough
to declare: ‘The time has come to close the
book on infectious diseases. We have basically
wiped out infection in the United States.’” Bill
Bryson: A Short History of Nearly Everything.
Beware of medical hubris.
Work habits:
Do it right: admitting patients.
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Proper H&P- all the stuff they told you in medical
school.
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Yes, you need a ROS.
Illegible notes don’t help a whole lot. You can actually use
more than one page.
You can’t hear through clothing.
Rectal and breast and pelvic and testicular exams really do
need to be done- if by no one else, then by you.
Problem oriented notes. No loose ends. Revisit and
revise your list daily.
Get the old records on admission. And read them.
Do it right: Discharging patients.
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Discharge summaries are important- do it now.
Concise, to the point, with meds.
Fill out the summary (patient instruction) sheets.
Patient instructions: the most important:
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Nature of illness and diagnosis
What was done
Medications: what they are for, how long to take them,
refills? Can the patient afford them? Can she read your list?
Followup: when, where, with whom, and what to
watch out for.
Getting along with people:
“It is for you to give the Orders & if they are bungled –
except for the King, the Archbishop of Canterbury & the
Speaker you can sack anyone & everyone – Therefore with
this terrific power you must combine urbanity, kindness and
if possible Olympic calm....I cannot bear that those who
serve the Country & yourself should not love you as well as
admire and respect you – Besides you won’t get the best
result by irascibility and rudeness. They will breed either
dislike or a slave mentality....”
Clementine Churchill to Winston Churchill, 1940
(Jenkins, R.: CHURCHILL)
“No man resolved to make the most of himself,
can spare time for personal contention. Still less
can he afford to take all the consequences,
including the vitiating of his temper, and the
loss of self-control. Yield larger things in which
you can show no more than equal right; and
yield lesser ones, though clearly your own.”
Abraham Lincoln, quoted in Team of Rivals.
Nurses (et al): Your best friend, your
worst enemy.
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Your choice.
There are some really smart, experienced,
nurses, therapists, etc., around here. Take their
advice seriously. You might even ask them?
Don’t be arrogant:
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There are no ancillary personnel
There is no excuse for discourtesy
Don’t yell (even quiet sarcasm has its limits)
Dress to make your mother proud
Remember, you know a lot, but you really don’t
know much (and you’ll never know enough)
Yeah, we know it’s hard:
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However:
“80% of life is showing up [on
time]”
-Woody Allen
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Be where you’re supposed to be when you’re
supposed to be there.
Doctors have no more excuse for tardiness than
anyone else.
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See “don’t be arrogant.”
Conferences, meetings, rounds start on time. Be
there.
Learn to organize your time - now.
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You only get a maximum of 5 admissions.
Don’t complain too much.
Excessive bitching leads to tedious, repetitive,
lengthy anecdotes (war stories) from aging
attending physicians.
Avoid these at all costs.
You think you’re having a tough day?
Sick People
“We must walk this lonesome valley
We have to walk it by ourselves
O, nobody can walk it for us
We have to walk it by ourselves.”
African-American Spiritual
“Now, wearily, desperately, the old enfeebled mind
was trying to grope with the strange and bitter
miracle of life, to get some meaning out of that
black, senseless fusion of pain and joy and agony,
that web that had known all the hope and joy and
wonder of a boy, the fury, passion, drunkenness, and
wild desire of youth, the rich adventure and
fulfilment of a man, and that had led him to this fatal
and abominable end.”
Thomas Wolfe: OF TIME AND THE RIVER.
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Illness is personal tragedy.
The emotional impact of a life-threatening
illness cannot be exaggerated.
Sickness:
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Inconvenience.
Interference with recreation.
Loss of control.
Loss of livelihood.
Embarrassment.
Pain.
Fear.
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Discuss emotional issues openly with patients.
Talk to families.
Don’t avoid the dying patient or talking about
death.
Take advice from the nurses; they’re around the
patient much more than you.
The most skilled physician who lacks
compassion isn’t worth much.
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“One truth has not changed from the time of
Hippocrates to today: when faced with desperate
patients, doctors often do not have the heart – or, more
accurately, they have too much heart – to do nothing.
And so a doctor, as desperate as the patient, may try
anything, including things he or she knows will not
work as long as they will do not harm.” Barry, The
Great Influenza.
Do the right thing, not the least painful (for you.)
Learning from your patients:
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“I am in awe of them, and I feel privileged to have
been a witness to their lives and their sacrifices….As I
came to know many of them and their stories, I
became more convinced of my judgement on that day
marking the fiftieth anniversary of D-Day. This is the
greatest generation any society has produced.” Tom
Brokaw. The Greatest Generation.
Get to know your patients. Look at the pictures on the
nightstand. Everyone has a story. You will be richer
for hearing it.
Propriety:
Patient privacy:
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Don’t gossip: this includes your spouse,
significant other, friends, colleagues.
Knock; close the door, pull the curtain.
Talk about sports in the elevators.
Spare patients embarrassment whenever
possible.
It embarrasses me that someone thought we
needed HIPPA.
Frustration
Frustration
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“Some days you think maybe you know
everything…some days you think maybe you
don’t know anything…some days you think you
know a few things…some days you don’t even
know how old you are.”
Peanuts, DMN, 04/16/06.
Frustration:
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“Life is not fair.” Your mother
“Life is hard, then you die.” Gabriel Shapiro,
oncologist
“If you want justice, go to divinity school.”
Bruce Johnston, Seattle attorney.
Illness is terribly unfair- at times overwhelmingly
so.
Frustration:
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“A passive airbag is clearly a supplemental safety
device; it’s reasonably effective, though- like the
rest of life itself- not without tradeoffs. If you
do choose to ignore the seatbelt, the rest of us
shouldn’t honestly care what the airbag does to
you.” Dennis Simanaitis, Road & Track, June
1997.
Frustration:
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“Why should I be out here risking my life when
people are doing this shit?” U.S. Marine
infantryman, commenting on a drive-by
shooting.
Frustration:
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Non-compliance is a fact of life.
People do stupid, dangerous, repulsive,
reprehensible things.
We have to treat them anyway.
And don’t forget, people do courageous, selfless,
humane things.
We get to treat them too.
“Who is John Galt?” Ayn Rand:
ATLAS SHRUGGED.
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Learn to deal with the bureaucracy.
Pick the mountains you want to die on (Bruce
Wall.)
Don’t “go along to get along.”
Occasional hell-raising ain’t so bad.
Integrity:
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“The acceptance of individual gifts, hospitality,
trips, and subsidies of all types from the health
care industry by an individual physician is
strongly discouraged. The acceptance of even
small gifts has been documented to affect
clinical judgment and heightens the perception
(as well as the reality) of a conflict of interest.”
Ethics Manual, ACP, Ann.Int.Med 142:572
Integrity:
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The lure of money: Buick vs. BMW.
Medical fads- cashing in. Botox anyone?
Viagra?
Professional witnesses.
The drug companies. Are you for sale? What
are you doing for dinner?
Citizenship and Social Responsibility
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Stepping outside the medical box.
Be a citizen:
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Participate in the community.
Many of the health issues of this era must be
solved at the community rather than the
individual level.
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“The things that will destroy America are
prosperity at any price, peace at any price, safety
first instead of duty first, the love of soft living
and the get-rich-quick theory of life.”
Theodore Roosevelt
Being a physician does not absolve
you of other social responsibilities.
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“Underlying such privatization is a misguided
belief that the elite can remain unaffected by the
problems of society around them: the attitude
of those Greenland Norse chiefs who found
that they had merely bought themselves the
privilege of being the last to starve.”
Jared Diamond: COLLAPSE
Scared yet?
Medicine:
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An endurance sport?
A religious calling?
Balancing detachment and
compassion.
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“We were eating supper and they brought in one
of the locals who had been shot in the head.
There was nothing we could do for him, so we
dragged his stretcher out into the field, and went
back to finish supper.” U.S.Army major,
Nicaragua, 1972.
Learn to leave it at work.
Personal
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Keep you profession and your family central in your
life; you won’t have time for much else.
Don’t overspend or become obsessed with money.
Alcohol and drugs are real hazards.
Go to the gym.
Read a non-medical book.
If you feel depressed, talk to one of us- don’t wait for a
crisis.
“The loneliness of the long distance
runner.” 1962 film.
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You’re better, and tougher, than you think you
are.
Things nearly always work out.
This day, too, will pass.
Enjoy the next forty years.
Most of you will.