How to be a good intern

1. How to be a good intern • AKA: • PGY-1 • R-1 • Wedge

2. Why be a doctor? An opportunity to participate in the center of the human drama: Life and death, not life on the periphery

3. Growing up medically:

4. Internship is the seminal year of your career • 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

5. Mandated intern hours: • “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: ABSOLUTEFRIENDS • The rule makers may not always get the picture.

6. Mandated intern hours: • 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.

7. Internship: 1967 • 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

8. Internship: 22006 • 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.

9. The difference: • 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.

10. Learning: • Look things up: • 1967: The Index Medicus (tedious) • 2006: Pubmed, Uptodate, etc., etc. (easy) • Look things up: • 1967: Later • 2006: Real time (like now) • A compassionate physician who is inept is still inept. • Don’t operate on hearsay. You have to read.

11. Skills vs. Knowledge • Skills: increasingly demanding of our time and intellectual capital; and a source of mental clutter? • 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. • Thinking about what you are doing. • Making decisions based on thinking. • Your brain as a manual transmission.

12. 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.

13. “You frag ‘em, we bag ‘em.” Motto on a mortuary truck, Vietnam. • “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.

14. “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: AShortHistoryofNearlyEverything. • Beware of medical hubris.

15. Work habits:

16. Do it right: admitting patients. • Proper H&P- all the stuff they told you in medical school. • 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.

17. Do it right: Discharging patients. • Discharge summaries are important- do it now. Concise, to the point, with meds. • Fill out the summary (patient instruction) sheets. • Patient instructions: themostimportant: • 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.

18. Getting along with people:

19. “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)

20. “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.

21. Nurses (et al): Your best friend, your worst enemy. • Your choice. • There are some really smart, experienced, nurses, therapists, etc., around here. Take their advice seriously. You might even ask them?

22. Don’t be arrogant: • 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)

23. Yeah, we know it’s hard: • However:

24. “80% of life is showing up [on time]”-Woody Allen • Be where you’re supposed to be when you’re supposed to be there. • Doctors have no more excuse for tardiness than anyone else. • See “don’t be arrogant.” • Conferences, meetings, rounds start on time. Be there. • Learn to organize your time - now.

25. 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.

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

27. Sick People

28. “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

29. “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: OFTIMEANDTHERIVER.

30. Illness is personal tragedy. • The emotional impact of a life-threatening illness cannot be exaggerated.

31. Sickness: • Inconvenience. • Interference with recreation. • Loss of control. • Loss of livelihood. • Embarrassment. • Pain. • Fear.

32. 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.

33. “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, TheGreat Influenza. • Do the right thing, not the least painful (for you.)

34. Learning from your patients:

35. “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.

36. Propriety:

37. Patient privacy: • 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.

38. Frustration

39. Frustration • “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.

40. Frustration: • “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.

41. Frustration: • “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.

42. Frustration: • “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.

43. Frustration: • 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.

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

45. Integrity: • “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

46. Integrity: • 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?

47. Citizenship and Social Responsibility • Stepping outside the medical box.

48. Be a citizen: • Participate in the community. • Many of the health issues of this era must be solved at the community rather than the individual level.

49. “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

50. Being a physician does not absolve you of other social responsibilities. • “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