Countdown to July 1: PGY1

It is somewhat common knowledge that if you're going to pick a day to avoid the hospital, July 1 is the day. The hospital is awash with not only new interns but also senior residents still green with inexperience. And if you are a PGY1, welcome to Hell.

I remember the day after I graduated medical school, I was driving down the highway and saw a car run off the road and crash. As I drove by, I thought to myself, 'That person could really use a doctor...' Then it occurred to me: OH FUCK, that doctor is me!

The nightmare of intern year has been immortalized in the book, 'House of God' by Sam Shem, and I am sad to say that for the most part it still holds true after 30+ years. Intern year is still the singular worst one year period of medical education.

It is dehumanizing. It is humiliating. It is frustrating. And it wipes away any confidence or boldness carried over from medical school. MS3's complain that they've never felt so stupid as during third year, but that pales in comparison to intern year. At least during third year, your ignorance didn't hurt anyone but yourself. Now, what you don't know kills people.

The training goals of intern year are to learn patient care and disease management. However, what I walked away with was this: I learned what kind of doctor I am. The intern will learn what kind of doctor he is. Is he someone who fudges records? Does he take shortcuts? Does he stay late every day to tie up loose ends? Is he overly confident? Is he gun shy? By the end of PGY 1, an intern will know what kind of doctor he is, and he will spend the rest of his career either accepting that fate or fighting against it.

Some advice for new PGY1's
-If you can, wear scrubs all the time.
-Making friends with the nurses will improve your Rounding-Fu*.
-When you go home, leave the patients at the hospital.
-Make yourself a 'Laws of the House of God' checklist.
-Finally, but most importantly, the most valuable thing I learned during intern year was: sleeping is more important than eating.

*Rounding-Fu: How badass you are during rounds

Let's shit on the interns

July in the hospital means one thing: new interns. It's common knowledge that going to the hospital in July is risky business. I know the new interns are here because I can hear the staff complaining. Every third sentence starts, 'Those dumb interns... *sigh*!' To everyone out there bitching about the interns' growing pains, I'd like to say this: STFU!

When I was a new intern, I caught flack from everyone: my attending, my senior, RN's, PCT's, MA's, RT's, EMT's, PT's, OT's, case managers, and even some custodial staff (strangely enough, I never heard a bad word from social work or nutrition...). I discovered one universal truth to being an intern in July: no one has your back.

My intern hell continued until my ICU month. Nurse Battle Axe was taking care of one of my patients. BA had been doing critical care since I was in diapers. The amount of critical care knowledge she would lose in a particularly violent sneeze was still more than I knew. So, when she asked me a question, I assumed it was rhetorical.

"I asked, 'What do you want to do, doctor?'" she repeated. My patient had a blood pressure of 70/30 despite aggressive hydration. I had no clue what to do. So, I sat down and thought about it, and after a little soul searching, I decided to start a pressor.

"Um, can we start dopamine? ... please?"

"Sure, doc!" she replied, and walked into the room, pushed a button on an IV pump, and dopamine was in. BP improved to 90/60. Mission accomplished.

Later, I thought about it, and she must've had the dopamine hung already and the line primed. But she let me make the call. I asked her about it, and she told me, "Dr. ifinding, you know I've always got your back!"

Part of being an intern is painful, and that's just how it is, but it certainly doesn't have to be more painful than it already is. So take it easy on the interns, huh? Or at least don't badmouth them to their face.

31 flavors and then some

Interns come in so many different flavors, and it can be hard to be a senior resident. Being a senior is a unique skill, and so I hope that I can provide a little guidance.

1. the stupid — his fund of knowledge is bankrupt.
   
2. the slacker — rounding on time? Not this guy.
   
3. the cluttered — Most labcoats have 5 pockets. This 'tern needs more.
   
4. the superstar — what I told one of my superstar 'terns: "I love having you on service. I get to eat a nice long breakfast."
   
5. the casual — He is completely frustrating in his unflappability. You'd swear he smokes pot.
   
6. the procedurist — He is single-minded in his focus to do every humanly possible procedure. But H+P? Pass.
   
7. the overwhelmed — One of my interns spent 4 hours doing an H+P. Think about that. FOUR HOURS.
   
8. the workaholic — His solution to all problems is work harder. While admirable, not always the best policy.
   
9. the earnest — "Well, I didn't document a skin exam because I didn't look at all of his skin, just his head, neck, chest, admonen, and legs." An actual quote.
   
10. the overconfident — He does not know what he does not know.
    
11. the disrespectful — I had one intern who was so disrespectful that I actually told him, "What makes you think you know anything?" I am not above putting a disrespectful intern in his place.
    
12. the unprofessional — All the above, while quirky, are just aspects of all of our personalities. At some point in time, we were all one of these flavors of intern. But without fail, the most dangerous intern is the unprofessional one. From a core competencies standpoint, knowledge can be taught, systems can be navigated, practice based learning speaks for itself, communication can be instructed, but you can't teach how to be professional. One of my attendings said something profound on the matter: "Ifinding, tell me, how do you teach someone that lying is wrong? I don't have a fix for that."

It may sound like I'm hating on the interns, but the truth of the matter is this: if you are an intern, there are only two things that any senior resident are looking for. He wants you to (1) work hard and (2) give a damn. Everything else can be taught. And my favorite interns aren't the smartest or most talented, but the ones who I called at 4AM and still got the job done.

I'm sure that I'm forgetting about some flavors of interns. Feel free to leave a comment with your favorite flavor of intern.

A first death

Closing in on the end of the residency year, most of the interns have earned their first death. Some took their time. Some didn’t have to wait too long at all. All in all, I find that the reactions that they have to death are quite different and sometimes offer a unique insight.

The experience of death is a little different for each of them. Getting called by the nurse at 4 AM and being told that Mrs. R expired is quite different from being the person pumping on Mrs. R’s chest, and even this is more insulated than being the person having to tell Mrs. R’s family that there’s nothing more that we can do. And all of this is easy compared to being the person who forgot to write for an antibiotic for Mrs. R’s positive blood culture.

When a patient dies, some of the interns are relieved. The patient is no longer going to torture the intern with really hard decisions and clinical questions, many of which are life or death types of choices. It’s all over now. No more stress. Maybe the intern can get some sleep now.

Some are utterly devastated. There was so much emotional involvement, and now, no outlet. It feels like gas in your stomach, and you can’t belch it out. And it hurts in a deep way that can’t be easily resolved. You can’t talk yourself out of it. Some people drink themselves out of it.

And sometimes, every now and then, you’ll meet someone who just doesn’t care. They take the news of their patient’s death with the same attitude that someone from Nebraska would have about the Mets losing the NLCS.

I thought for sure that I would be the destroyed person when I had my first death. I thought it would empty me out and hurt me in ways that I couldn’t even comprehend. But surprisingly, I found myself in the ‘don’t care’ column. A nurse called me to pronounce on a patient that was DNR. I went to bedside, pronounced the patient, and then went back to bed.

Since then, I’ve had a lot of other death experiences, and they’ve run the gamut of relief to devastation. But I’ve always felt a little guilty about Mrs. R. Not that I did anything wrong per se but her death was so forgettable to me, and that my reaction was not one of sadness, but of relief.

I’ve since had some surprisingly hard deaths, deaths where I was so angry and so disappointed with myself that I threw things and slammed doors. I punched a door so hard that I thought I broke my hand. And I remember one death where I went balls to the wall in treatment, I talked the family out of a DNR, and after 8 hours of very aggressive treatment, the patient had a systolic pressure of 50/20. I talked to the family and we went to comfort care, and I threw things and cursed and was so angry. I did everything right, and even then, I failed.

Each death is a little different, and in the end, I find that it helps to insulate yourself a little. Each death hurts, and rather than pouring yourself out each time, it helps to ration out your compassion a bit. I know it sounds cold, but the human soul can only bear so much suffering.

Hardass

I thought I put this up a while ago, but I guess not. Here we go. I wrote this like a year ago...

When I was a medical student, I worked with one senior resident, Dr Hardass. He really pushed us, and it was a really tough month. He did however teach us almost continuously, and he made us really excited about medicine. I couldn't say enough about the guy. He was what I wanted to become. I wanted to be that good, and that dedicated. He was the ideal senior resident. I wanted to do well to prove myself to him.

So, when I became a senior resident, I thought of him while working with medical students and interns. I was tough on my interns, and I held my interns to a high standard. Some complained, but others really responded to the tough love.

In the end however, I felt vindicated. Some of the students and interns thanked me. They were so happy to be held to a high standard. I would tell the students that they had it easy, and they challenged me. They took on bigger patient loads, wrote sharper notes. It was impressive.

It was my belief that I have to hold people to a high standard, not just acceptable but excellence. If you only ever expect passable effort, that's all you'll ever get. Holding people to excellence breeds excellent effort.

There are no exceptions, especially for myself. I set out to be like Dr Hardass, and I think I did a decent job getting there, and now I'm considered by a lot of students to be their favorite resident. It's an honor.

The weird thing about being a resident is that it's a chance to be a mentor, and that really is a sacred duty, because your actions are the basis for students' view of what being an excellent resident is.

One of my friends told me that I'm an exceptional leader because I listen to others, always try to do my best, and trust others to rise to the occasion. And those who've worked with me felt they should excel too, not just for the sake of excellence, but also because they didn't want to let me down. That's an awesome feeling.

Yeah, I'm a hardass, but that's DOCTOR Hardass to you.

Apparently, I'm a jerk

Patients LOVE me. I mean it. I'm not being facetious or pumping my ego. At least once a week, I have a patient talk me up, or try to get into my residency clinic. When I was still taking patients, I had to turn these people away out of fear that I'd be accused of poaching. Even today, a nurse told me that one of the patients I saw a month or two ago, this patient saw me in the hall, and the patient couldn't stop talking about me.

So, I was a little surprised to find out that apparently, I'm the jerk senior resident. I'm the guy that yells at the interns and is too critical. I'm always in a bad mood and never fun to work with. I make the interns work too hard. No one wants to work with me.

And as much as I'd like to deny it... it's TRUE! I'm a jerk! How dare I make the interns work, and demand that they meet a standard of excellence? I'm such an asshole. I am the Dr. Perry Cox of my institution (except I'm nice to patients). If you're an intern, let me tell you how to stay off my shit list.

1. Don't lie about your skills. Nothing pisses me off more than an intern misrepresenting his skills. I've had interns tell me they were experienced with central lines, only to find out that I was supervising their first attempt at a CVC. Not cool. I don't mind teaching a procedure, but I need to know that you don't know.
   
   
2. Don't complain about working. I've had interns complain and whine and bitch about doing FOUR OR FIVE admissions. Christ! Who the fuck complains about that? Compared to my intern year, these guys are getting off light. I've got absolutely no sympathy. If you didn't want to work hard, you should've become a janitor.
   
   
3. Mistakes are okay. Stupidity is not. Not knowing which antibiotic to use, that's okay. Not knowing which stress test to order, fine. Not being able to write an H&P, that's a big fucking problem.
   
   
4. Fucking up is okay. Being lazy is not. You're an intern. You'll make mistakes. That's FINE. What is not fine is not doing something because it is inconvenient. I have actually stood at bedside and made interns do rectal exams on patients when indicated, because not doing one when it's indicated is practically criminal. I've been so adamant about this that several interns think I have a butt fetish.
   
   
5. Don't help unless you know that your efforts will actually help. True story. I put in a central line, showing the intern how to do it. While I was sewing it down, he tried to clean up my sharps. I didn't notice. Then he gets paged away. I turn around and I can't find the guide wire. SHIT. SHIT SHIT SHIT SHIT SHIT SHIT. By the time he got back, I had a 911 page out to vascular surgery and super stat portable x ray.

I had a coworker in college. I was applying for a student supervisor position at the job, but he begged me not to do it. Why? "Ifinding, you're a good guy, and you would be awesome at supervisor, and I have no doubt that you'd get all kinds of stuff done, but it's a part time college job for beer money. You'd never let us be lazy. You take this too seriously."

I think the same is true now that I'm a senior resident. I demand a standard of excellence from my interns, and I'm not talking about technical proficiency. I'm talking about integrity, honestly, respect, humility, and compassion. These are requisites to being an excellent doctor. And if you're not interested in being an excellent doctor, I'm not interested in teaching you.