How to be a good internHow to be a good intern

AKA:AKA: PGY-1PGY-1 R-1R-1 WedgeWedge

Why be a doctor? An Why be a doctor? An opportunity to participate opportunity to participate in the center of the human in the center of the human

drama:drama:

Life and death, not life on the Life and death, not life on the peripheryperiphery

Growing up medically:Growing up medically:

Internship is the seminal Internship is the seminal year of your careeryear of your career

You will work harder (I hope)You will work harder (I hope) You will learn moreYou will learn more You will acquire more responsibilityYou will acquire more responsibility You will form work habits for a You will form work habits for a

lifetime- good or badlifetime- good or bad

Mandated intern hours:Mandated intern hours: ““The lines Mundy previously mistook for life The lines Mundy previously mistook for life

experience are the lines of an overindulged child experience are the lines of an overindulged child who has never been beaten up by anybody’s who has never been beaten up by anybody’s police or crossed bad borders, or been locked police or crossed bad borders, or been locked away in the White Hotel or hog-tied and chained away in the White Hotel or hog-tied and chained to the floor of a helicopter. In this respect he to the floor of a helicopter. In this respect he embodies what Mundy considers the least embodies what Mundy considers the least attractive characteristic of both our Western attractive characteristic of both our Western leaders and their spokesmen: a levitational self-leaders and their spokesmen: a levitational self-belief that nimbly transcends the realities of belief that nimbly transcends the realities of human suffering.” John Le Carre: human suffering.” John Le Carre: ABSOLUTEABSOLUTE FRIENDS FRIENDS

The rule makers may not always get the picture. The rule makers may not always get the picture.

Mandated intern hours:Mandated intern hours: However misguided we may find these However misguided we may find these

rules, they are the rules and must be rules, they are the rules and must be followed.followed.

““I’m not going to be one of those people I’m not going to be one of those people who gets old and says ‘I wish I had done who gets old and says ‘I wish I had done this. I wish I had done that.’ Every once in this. I wish I had done that.’ Every once in a while, you’ve got to do something hard, do a while, you’ve got to do something hard, do something you’re not comfortable with. A something you’re not comfortable with. A person needs a gut check.” U.S.Marine, person needs a gut check.” U.S.Marine, Fallujah, DMN 11/21/04Fallujah, DMN 11/21/04

Regardless of the rules, this is your year to Regardless of the rules, this is your year to do something hard.do something hard.

Internship: 1967Internship: 1967

Every other night on call.Every other night on call. ½ dozen antibiotics½ dozen antibiotics ½ dozen cardiac drugs½ dozen cardiac drugs Very limited radiologyVery limited radiology Interns do much lab work, draw Interns do much lab work, draw

blood, start iv’s, pass NG tubes, blood, start iv’s, pass NG tubes, foleys, etc.foleys, etc.

Wages $5100Wages $5100 Interns bitch a lotInterns bitch a lot

Internship: 2Internship: 220062006

Every 4Every 4thth night, off at 1330, limited hours. night, off at 1330, limited hours. Dozens of antibiotics.Dozens of antibiotics. Dozens of cardiac drugs.Dozens of cardiac drugs. Numerous, complex imaging techniques.Numerous, complex imaging techniques. Interns write lots of orders.Interns write lots of orders. Interns uncertain as to location of veins.Interns uncertain as to location of veins. Interns uncertain as to location of lab.Interns uncertain as to location of lab. Invasive radiologists do lots of Invasive radiologists do lots of

procedures.procedures. Wages $35,000+.Wages $35,000+. Interns bitch a lot.Interns bitch a lot.

The difference:The difference:

1967: Learning by passive 1967: Learning by passive absorptionabsorption

2006: Learning by active transport.2006: Learning by active transport. You will have (relatively) a great You will have (relatively) a great

deal of free time; how you use it will deal of free time; how you use it will have a major impact on your skills as have a major impact on your skills as a physician.a physician.

Learning:Learning:

Look things up:Look things up: 1967: The Index Medicus (tedious)1967: The Index Medicus (tedious) 2006: Pubmed, Uptodate, etc., etc. (easy)2006: Pubmed, Uptodate, etc., etc. (easy)

Look things up:Look things up: 1967: Later1967: Later 2006: Real time (like now)2006: Real time (like now)

A compassionate physician who is inept A compassionate physician who is inept is still inept.is still inept.

Don’t operate on hearsay. You have to Don’t operate on hearsay. You have to read.read.

Skills vs. KnowledgeSkills vs. Knowledge

Skills: increasingly demanding of our time Skills: increasingly demanding of our time and intellectual capital; and a source of and intellectual capital; and a source of mental clutter?mental clutter? Finding the cafeteria, where to park, etc.Finding the cafeteria, where to park, etc. Learning to use the computer system, your PDA, Learning to use the computer system, your PDA,

and filling out numerous forms.and filling out numerous forms. Algorithms. Algorithms. Your brain as an automatic transmission.Your brain as an automatic transmission.

Knowledge: using your brain for what it was Knowledge: using your brain for what it was designed.designed. Thinking about what you are doing.Thinking about what you are doing. Making decisions based on thinking.Making decisions based on thinking. Your brain as a manual transmission.Your brain as a manual transmission.

Distractions:Distractions:

““According to a 2005 British study According to a 2005 British study commissioned by Hewlett Packard, workers commissioned by Hewlett Packard, workers who constantly interrupt tasks in order to who constantly interrupt tasks in order to respond to e-mail, text messages and phone respond to e-mail, text messages and phone calls suffer a 10-point drop in I.Q. following calls suffer a 10-point drop in I.Q. following the distractions. That’s more than double the the distractions. That’s more than double the drop in I.Q. experienced by marijuana drop in I.Q. experienced by marijuana smoke.”smoke.”

DMN, 05/29/06DMN, 05/29/06

Learn to focus amid the chaos.Learn to focus amid the chaos.

““You frag ‘em, we bag ‘em.” You frag ‘em, we bag ‘em.”

Motto on a mortuary truck, Motto on a mortuary truck, Vietnam.Vietnam.

““The burden of harm conveyed by The burden of harm conveyed by the collective impact of all of our the collective impact of all of our health care quality problems is health care quality problems is staggering.” U.S. Institute of staggering.” U.S. Institute of Medicine ReportMedicine Report

Try really hard not to add to the Try really hard not to add to the burden of iatrogenesis.burden of iatrogenesis.

““In 1952, penicillin was fully effective In 1952, penicillin was fully effective against all strains of staphylococcus against all strains of staphylococcus bacteria, to such an extent that by the bacteria, to such an extent that by the early 1960s the U.S. surgeon general, early 1960s the U.S. surgeon general, William Stewart, felt confident enough to William Stewart, felt confident enough to declare: ‘The time has come to close the declare: ‘The time has come to close the book on infectious diseases. We have book on infectious diseases. We have basically wiped out infection in the basically wiped out infection in the United States.’” Bill Bryson: United States.’” Bill Bryson: AA ShortShort HistoryHistory ofof NearlyNearly EverythingEverything..

Beware of medical hubris.Beware of medical hubris.

Work habits:Work habits:

Do it right: admitting Do it right: admitting patients.patients.

Proper H&P- all the stuff they told you in Proper H&P- all the stuff they told you in medical school.medical school. Yes, you need a ROS.Yes, you need a ROS. Illegible notes don’t help a whole lot. You can Illegible notes don’t help a whole lot. You can

actually use more than one page.actually use more than one page. You can’t hear through clothing.You can’t hear through clothing. Rectal and breast and pelvic and testicular exams Rectal and breast and pelvic and testicular exams

really do need to be done- if by no one else, then by really do need to be done- if by no one else, then by you.you.

Problem oriented notes. No loose ends. Problem oriented notes. No loose ends. Revisit and revise your list daily.Revisit and revise your list daily.

Get the old records on admission. And read Get the old records on admission. And read them.them.

Do it right: Discharging Do it right: Discharging patients.patients.

Discharge summaries are important- do it Discharge summaries are important- do it now. Concise, to the point, with meds.now. Concise, to the point, with meds.

Fill out the summary (patient instruction) Fill out the summary (patient instruction) sheets.sheets.

Patient instructions: Patient instructions: thethe mostmost importantimportant:: Nature of illness and diagnosisNature of illness and diagnosis What was doneWhat was done Medications: what they are for, how long to take Medications: what they are for, how long to take

them, refills? Can the patient afford them? Can them, refills? Can the patient afford them? Can she read your list?she read your list?

Followup: when, where, with whom, and Followup: when, where, with whom, and what to watch out for. what to watch out for.

Getting along with Getting along with people:people:

““It is for you to give the Orders & if they are It is for you to give the Orders & if they are bungled – except for the King, the Archbishop bungled – except for the King, the Archbishop

of Canterbury & the Speaker you can sack of Canterbury & the Speaker you can sack anyone & everyone – Therefore with this anyone & everyone – Therefore with this

terrific power you must combine urbanity, terrific power you must combine urbanity, kindness and if possible Olympic calm....I kindness and if possible Olympic calm....I

cannot bear that those who serve the Country cannot bear that those who serve the Country & yourself should not love you as well as & yourself should not love you as well as

admire and respect you – Besides you won’t admire and respect you – Besides you won’t get the best result by irascibility and get the best result by irascibility and

rudeness. They will breed either dislike or a rudeness. They will breed either dislike or a slave mentality....”slave mentality....”

Clementine Churchill to Winston Churchill, Clementine Churchill to Winston Churchill, 19401940

(Jenkins, R.: CHURCHILL)(Jenkins, R.: CHURCHILL)

““No man resolved to make the most of No man resolved to make the most of himself, can spare time for personal himself, can spare time for personal contention. Still less can he afford to take contention. Still less can he afford to take all the consequences, including the vitiating all the consequences, including the vitiating of his temper, and the loss of self-control. of his temper, and the loss of self-control. Yield larger things in which you can show no Yield larger things in which you can show no more than equal right; and yield lesser more than equal right; and yield lesser ones, though clearly your own.”ones, though clearly your own.”

Abraham Lincoln, quoted in Abraham Lincoln, quoted in Team of RivalsTeam of Rivals..

Nurses (et al): Your best Nurses (et al): Your best friend, your worst enemy.friend, your worst enemy.

Your choice.Your choice. There are some really smart, There are some really smart,

experienced, nurses, therapists, etc., experienced, nurses, therapists, etc., around here. Take their advice around here. Take their advice seriously. You might even ask them?seriously. You might even ask them?

Don’t be arrogant:Don’t be arrogant:

There are no ancillary personnelThere are no ancillary personnel There is no excuse for discourtesyThere is no excuse for discourtesy Don’t yell (even quiet sarcasm has Don’t yell (even quiet sarcasm has

its limits)its limits) Dress to make your mother proudDress to make your mother proud Remember, you know a lot, but you Remember, you know a lot, but you

really don’t know much (and you’ll really don’t know much (and you’ll never know enough)never know enough)

Yeah, we know it’s hard:Yeah, we know it’s hard:

However:However:

““80% of life is showing up 80% of life is showing up [on time]”[on time]”

-Woody Allen-Woody Allen Be where you’re supposed to be Be where you’re supposed to be

when you’re supposed to be there.when you’re supposed to be there. Doctors have no more excuse for Doctors have no more excuse for

tardiness than anyone else.tardiness than anyone else. See “don’t be arrogant.”See “don’t be arrogant.”

Conferences, meetings, rounds start Conferences, meetings, rounds start on time. Be there.on time. Be there.

Learn to organize your time - now.Learn to organize your time - now.

You only get a maximum of 5 You only get a maximum of 5 admissions.admissions.

Don’t complain too much.Don’t complain too much. Excessive bitching leads to tedious, Excessive bitching leads to tedious,

repetitive, lengthy anecdotes (war repetitive, lengthy anecdotes (war stories) from aging attending stories) from aging attending physicians.physicians.

Avoid these at all costs.Avoid these at all costs.

You think you’re having a You think you’re having a tough day?tough day?

Sick PeopleSick People

““We must walk this lonesome valleyWe must walk this lonesome valley

We have to walk it by ourselvesWe have to walk it by ourselves

O, nobody can walk it for usO, nobody can walk it for us

We have to walk it by ourselves.”We have to walk it by ourselves.”

African-American Spiritual African-American Spiritual

““Now, wearily, desperately, the old Now, wearily, desperately, the old enfeebled mind was trying to grope with enfeebled mind was trying to grope with the strange and bitter miracle of life, to the strange and bitter miracle of life, to

get some meaning out of that black, get some meaning out of that black, senseless fusion of pain and joy and senseless fusion of pain and joy and

agony, that web that had known all the agony, that web that had known all the hope and joy and wonder of a boy, the hope and joy and wonder of a boy, the fury, passion, drunkenness, and wild fury, passion, drunkenness, and wild

desire of youth, the rich adventure and desire of youth, the rich adventure and fulfilment of a man, and that had led fulfilment of a man, and that had led

him to this fatal and abominable end.”him to this fatal and abominable end.”

Thomas Wolfe: Thomas Wolfe: OFOF TIMETIME ANDAND THETHE RIVERRIVER..

Illness is personal tragedy.Illness is personal tragedy. The emotional impact of a life-The emotional impact of a life-

threatening illness cannot be threatening illness cannot be exaggerated.exaggerated.

Sickness:Sickness:

Inconvenience.Inconvenience. Interference with recreation.Interference with recreation. Loss of control.Loss of control. Loss of livelihood.Loss of livelihood. Embarrassment.Embarrassment. Pain.Pain. Fear.Fear.

Discuss emotional issues openly with Discuss emotional issues openly with patients.patients.

Talk to families.Talk to families. Don’t avoid the dying patient or talking Don’t avoid the dying patient or talking

about death.about death. Take advice from the nurses; they’re Take advice from the nurses; they’re

around the patient much more than you.around the patient much more than you. The most skilled physician who lacks The most skilled physician who lacks

compassion isn’t worth much.compassion isn’t worth much.

““One truth has not changed from the time of One truth has not changed from the time of Hippocrates to today: when faced with Hippocrates to today: when faced with desperate patients, doctors often do not have desperate patients, doctors often do not have the heart – or, more accurately, they have too the heart – or, more accurately, they have too much heart – to do nothing. And so a doctor, much heart – to do nothing. And so a doctor, as desperate as the patient, may try anything, as desperate as the patient, may try anything, including things he or she knows will not including things he or she knows will not work as long as they will do not harm.” work as long as they will do not harm.” Barry, Barry, TheThe Great Influenza.Great Influenza.

Do the right thing, not the least painful (for Do the right thing, not the least painful (for you.)you.)

Learning from your Learning from your patients:patients:

““I am in awe of them, and I feel privileged to I am in awe of them, and I feel privileged to have been a witness to their lives and their have been a witness to their lives and their sacrifices….As I came to know many of them sacrifices….As I came to know many of them and their stories, I became more convinced of and their stories, I became more convinced of my judgement on that day marking the fiftieth my judgement on that day marking the fiftieth anniversary of D-Day. This is the greatest anniversary of D-Day. This is the greatest generation any society has produced.” Tom generation any society has produced.” Tom Brokaw. The Greatest Generation.Brokaw. The Greatest Generation.

Get to know your patients. Look at the Get to know your patients. Look at the pictures on the nightstand. Everyone has a pictures on the nightstand. Everyone has a story. You will be richer for hearing it.story. You will be richer for hearing it.

Propriety:Propriety:

Patient privacy:Patient privacy:

Don’t gossip: this includes your spouse, Don’t gossip: this includes your spouse, significant other, friends, colleagues.significant other, friends, colleagues.

Knock; close the door, pull the curtain.Knock; close the door, pull the curtain. Talk about sports in the elevators.Talk about sports in the elevators. Spare patients embarrassment Spare patients embarrassment

whenever possible.whenever possible. It embarrasses me that someone It embarrasses me that someone

thought we needed HIPPA.thought we needed HIPPA.

FrustrationFrustration

Frustration Frustration

““Some days you think maybe you Some days you think maybe you know everything…some days you know everything…some days you think maybe you don’t know think maybe you don’t know anything…some days you think you anything…some days you think you know a few things…some days you know a few things…some days you don’t even know how old you are.”don’t even know how old you are.”

Peanuts, DMN, 04/16/06.Peanuts, DMN, 04/16/06.

Frustration:Frustration:

““Life is not fair.” Your motherLife is not fair.” Your mother ““Life is hard, then you die.” Gabriel Life is hard, then you die.” Gabriel

Shapiro, oncologistShapiro, oncologist ““If you want justice, go to divinity If you want justice, go to divinity

school.” Bruce Johnston, Seattle school.” Bruce Johnston, Seattle attorney.attorney.

Illness is terribly unfair- at times Illness is terribly unfair- at times overwhelmingly so.overwhelmingly so.

Frustration:Frustration:

““A passive airbag is clearly a A passive airbag is clearly a supplemental safety device; it’s supplemental safety device; it’s reasonably effective, though- like the reasonably effective, though- like the rest of life itself- not without rest of life itself- not without tradeoffs. If you do choose to ignore tradeoffs. If you do choose to ignore the seatbelt, the rest of us shouldn’t the seatbelt, the rest of us shouldn’t honestly care what the airbag does honestly care what the airbag does to you.” Dennis Simanaitis, Road & to you.” Dennis Simanaitis, Road & Track, June 1997.Track, June 1997.

Frustration:Frustration:

““Why should I be out here risking Why should I be out here risking my life when people are doing this my life when people are doing this shit?” U.S. Marine infantryman, shit?” U.S. Marine infantryman, commenting on a drive-by shooting.commenting on a drive-by shooting.

Frustration:Frustration:

Non-compliance is a fact of life.Non-compliance is a fact of life. People do stupid, dangerous, People do stupid, dangerous,

repulsive, reprehensible things.repulsive, reprehensible things. We have to treat them anyway.We have to treat them anyway. And don’t forget, people do And don’t forget, people do

courageous, selfless, humane things. courageous, selfless, humane things.

We get to treat them too.We get to treat them too.

““Who is John Galt?” Ayn Who is John Galt?” Ayn Rand: ATLAS SHRUGGED.Rand: ATLAS SHRUGGED.

Learn to deal with the bureaucracy.Learn to deal with the bureaucracy. Pick the mountains you want to die Pick the mountains you want to die

on (Bruce Wall.)on (Bruce Wall.) Don’t “go along to get along.”Don’t “go along to get along.” Occasional hell-raising ain’t so bad.Occasional hell-raising ain’t so bad.

Integrity:Integrity:

““The acceptance of individual gifts, The acceptance of individual gifts, hospitality, trips, and subsidies of all types hospitality, trips, and subsidies of all types from the health care industry by an from the health care industry by an individual physician is strongly individual physician is strongly discouraged. The acceptance of even discouraged. The acceptance of even small gifts has been documented to affect small gifts has been documented to affect clinical judgment and heightens the clinical judgment and heightens the perception (as well as the reality) of a perception (as well as the reality) of a conflict of interest.”conflict of interest.”

Ethics Manual, ACP, Ann.Int.Med 142:572Ethics Manual, ACP, Ann.Int.Med 142:572

Integrity:Integrity:

The lure of money: Buick vs. BMW.The lure of money: Buick vs. BMW. Medical fads- cashing in. Botox Medical fads- cashing in. Botox

anyone? Viagra?anyone? Viagra? Professional witnesses.Professional witnesses. The drug companies. Are you for The drug companies. Are you for

sale? What are you doing for sale? What are you doing for dinner?dinner?

Citizenship and Social Citizenship and Social ResponsibilityResponsibility

Stepping outside the medical box.Stepping outside the medical box.

Be a citizen:Be a citizen:

Participate in the community.Participate in the community. Many of the health issues of this era Many of the health issues of this era

must be solved at the community must be solved at the community rather than the individual level.rather than the individual level.

““The things that will destroy The things that will destroy America are prosperity at any price, America are prosperity at any price, peace at any price, safety first peace at any price, safety first instead of duty first, the love of soft instead of duty first, the love of soft living and the get-rich-quick theory living and the get-rich-quick theory of life.”of life.”

Theodore RooseveltTheodore Roosevelt

Being a physician does not Being a physician does not absolve you of other social absolve you of other social

responsibilities.responsibilities. ““Underlying such privatization is a Underlying such privatization is a

misguided belief that the elite can misguided belief that the elite can remain unaffected by the problems of remain unaffected by the problems of society around them: the attitude of society around them: the attitude of those Greenland Norse chiefs who found those Greenland Norse chiefs who found that they had merely bought themselves that they had merely bought themselves the privilege of being the last to starve.”the privilege of being the last to starve.”

Jared Diamond: Jared Diamond: COLLAPSECOLLAPSE

Scared yet?Scared yet?

Medicine:Medicine:

An endurance sport?An endurance sport? A religious calling?A religious calling?

Balancing detachment and Balancing detachment and compassion.compassion.

““We were eating supper and they We were eating supper and they brought in one of the locals who had brought in one of the locals who had been shot in the head. There was been shot in the head. There was nothing we could do for him, so we nothing we could do for him, so we dragged his stretcher out into the dragged his stretcher out into the field, and went back to finish field, and went back to finish supper.” U.S.Army major, supper.” U.S.Army major, Nicaragua, 1972. Nicaragua, 1972.

Learn to leave it at work. Learn to leave it at work.

PersonalPersonal

Keep you profession and your family Keep you profession and your family central in your life; you won’t have time central in your life; you won’t have time for much else.for much else.

Don’t overspend or become obsessed with Don’t overspend or become obsessed with money.money.

Alcohol and drugs are real hazards.Alcohol and drugs are real hazards. Go to the gym.Go to the gym. Read a non-medical book.Read a non-medical book. If you feel depressed, talk to one of us- If you feel depressed, talk to one of us-

don’t wait for a crisis.don’t wait for a crisis.

““The loneliness of the long The loneliness of the long distance runner.” 1962 distance runner.” 1962

film.film. You’re better, and tougher, than you You’re better, and tougher, than you

think you are.think you are. Things nearly always work out.Things nearly always work out. This day, too, will pass.This day, too, will pass. Enjoy the next forty years.Enjoy the next forty years. Most of you will.Most of you will.