Name:
Pearls for Surgical Interns and Medical Students (Podcast)
Description:
Pearls for Surgical Interns and Medical Students (Podcast)
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/b5676e00-989e-4f76-90d9-b6c18fd19a63/thumbnails/b5676e00-989e-4f76-90d9-b6c18fd19a63.jpg?sv=2019-02-02&sr=c&sig=9sbIQCpJGCbRl6QtsF1j669yFWPFCMEBGAmfjPYxMkk%3D&st=2024-05-05T03%3A54%3A22Z&se=2024-05-05T07%3A59%3A22Z&sp=r
Duration:
T00H53M48S
Embed URL:
https://stream.cadmore.media/player/b5676e00-989e-4f76-90d9-b6c18fd19a63
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/b5676e00-989e-4f76-90d9-b6c18fd19a63/Pearls20for20Surgical20Interns20and20Medical20Students.mp3?sv=2019-02-02&sr=c&sig=1gT%2FgPTnNF7awg4d8m%2F%2BCQIy6oyJk5V93vvROWyFijU%3D&st=2024-05-05T03%3A54%3A22Z&se=2024-05-05T05%3A59%3A22Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
>> Behind the Knife, the Surgery Podcast, where we take a behind the scenes intimate look at surgery from leaders in the field. [ Music ] Welcome to Behind the Knife, Medical Student and Intern Survival Guide. In this podcast series we focus on high yield topics relevant to medical students and surgical interns.
My name is Patrick Georgoff. >> And I'm Vahagn Nikolian. >> And we are your hosts. >> Alright, so today's topic is the first of two episodes focusing on incoming interns. Intern year is a challenging time, especially for the first few months. These episodes are designed to give you some tips and tricks to excel as an intern and to prepare you for some of the more difficult clinical scenarios you'll be called about. >> But today we're going to be focusing on some non-clinical issues and who better to talk about these issues than some of our exceptional colleagues at the University of Michigan.
And we have with us today, Dr. Craig Brown, Dr. Glen Wackum [phonetic], Dr. Valeria Valboania [phonetic], and Dr. Ryan Etan [phonetic]. And Glen and Craig are about to start their third year of residency, and Valeria and Ryan their second year. And so welcome very much to our esteemed panel of colleagues. >> Esteemed indeed. So, to drill down what our interns have learned about, we're going to ask them about what makes a successful intern year. We will ask each of them to provide some general pearls of wisdom, and find out about how they stayed organized and effective during the, sort of, long intern year process.
Additionally, we're going to ask them what they learned outside of the hospital, as well, to stay sane. >> Great, that sounds good. And before we get started, I want to encourage all of our listeners to check out episode number 15 on Behind the Knife, called Stuff Surgery Interns Should Know. This is an absolutely awesome episode; it's got a lot of good stuff in it and we're just hoping to kind of build on that-- on that podcast. So, we're going to start with you, Ryan, with the first question.
And so, I was hoping you could provide us a pearl or two of wisdom that you could pass along to incoming interns that you found to be, you know, particularly useful. >> Alright. Hey everyone. My name's Ryan. I'm happy to be here. Let's get right into it. I'm going to start with, I think, the simplest but most important pearl I can tell you guys and that's kill them with kindness.
What I mean by that is-- is simply you should really be respectful and kind in as many of your interactions as you possibly can. You have to remember that you're going to be here for five maybe seven years or longer, and so you're going to be making relationships with people all over the hospital and it really behooves you not to be burning any bridges unnecessarily. You'd really be amazed how frequently this rule is broken in the setting of being a stressed out, overworked resident in the hospital, but the benefit of just being nice and thankful, and kind and respectful to as many as you possibly can, you'll find that it'll go a long way to make your life easier.
So, you really should, especially in the first months when you're establishing your reputation at your institution you should be super cognizant about how you're treating other people around you, and that-- that goes from obviously your co-residents and attendings, but also the OR nurses, the scrub techs, everyone. I have a-- my second piece of advice is a little bit less vague, but I think also helpful.
If you're taking overnight call, or when you're taking overnight call, I think a-- an excellent thing that you should start doing is checking in at the nursing stations every night. You'll find-- you'll-- you'll find soon that the-- the pain when you're trying to get those two hours of sleep at night of getting an order for Tums or Dulcolax order or Colace order and that wakes you up in the middle of the only two hours of sleep you're going to get, if you-- if you actually check in at the nursing stations at around nine p.m. or 10 p.m. and try to find every nurse who's taking care of your patients and just ask them, hey, what orders do you need me to throw in for your patients and that could really save you and you'll get maybe a couple-- a consecutive couple hours of sleep.
Those are my pearls. >> Yeah, I particularly like those. You know, especially when you're really stressed and someone is giving you a hard time, you can react in one of two ways, you could snap back or you can, like you said, kill them with kindness, and I couldn't agree more; I think that goes an absolutely long way. And as you mentioned early on, especially when people are trying to figure you out and trying to find out what you're all about, that's huge. Alright, Dr. Wacum. >> Before I start, I want to say I've been listing to Patrick and V for the last couple weeks on this Behind the Knife, and I'll say they sound much more articulate and intelligent [laughter] through a podcast than they do in person, so that's impressive.
My two pearls that I have; the first-- the first one I have is learn one thing from every patient you take care of. You know, I believe there's so much to learn about being a surgeon and people keep learning their entire career, and although people want to learn everything as soon as possible that's just really unrealistic. I think the best teachers we have are our patients because the lessons we've learned have a very real face behind them. That whenever I'm operating, or more typically during intern year, taking care of a patient perioperatively, I make it a point to find one thing I'm going to learn because of this patient.
I make the learning point small and level appropriate. For example, as an intern on a post-op whipple patient, I wasn't learning all the steps to performing a whipple but I did learn about Gaelic gastric emptying and the treatments for that. Sometimes it's as simple as this is a patient on a medicine I've never heard before and I'm going to go look up the indications, the mechanism of action and side effects. My second pearl I have is load the boat. This is my favorite saying from all intern year, which basically means don't go down on a sinking ship alone; make sure you load the boat full of people.
This means ask early and often for help. Intern year is a great year for a lot of independent thought, but not so great for a ton of independent action. We know you guys are smart, you get to all these programs, you know a ton about physiology, but the truth is you've never taken care of actual patients before and there's a lot you don't know just because you haven't seen it before. And also, as I've gone through the years now, there's a lot you don't know because you're not usually in the room with chief staff with attendings and there's a lot of background to plans and thought process that you're just not privy to because you're going around checking boxes, so, you know, it's always good to talk to people when you run into any situation.
And I don't-- this doesn't mean you can't be a doctor and come up with plans and start initial workups, but it means when your post-op day one patient goes int afib with RVR, as soon as you order your labs, EKG and give them [inaudible] you better call, page, text or bat signal your se-- your senior. >> Awesome. Well thanks Glen, that was wonderful, sort of insights in terms of learning something from every patient, totally agree with that. You can learn a lot over time and a lot of residents through the years have said try to learn one thing every day or something from every patient, and I think over time it really adds up.
Additionally, loading the boat can really go a long way in making sure that you instill trust in your senior residents and your faculty because then they know that you'll call them when-- when you need them. So, with that said, let's move on to our next resident, Craig Brown. Why don't you give us a little-- some insights about some ways that people can be successful as interns? >> Yeah, V, thanks for having us on the show. I-- you know, I think the beauty of having these two guys, V and Patrick, is that coming in I learned all my pearls from these two guys, so hopefully you guys are in good hands.
My first pearl is really to approach every new clinical problem with a full evaluation and I think that that's natural in the clinic when you have a discrete compliant, but it really should actually continue even for small things on the floor, so if a patient comes in to the hospital and they have a [inaudible] section, and then post-operatively they develop nausea and vomiting it's really easy to jump to postoperative ileus as the explanation, but instead I would actually encourage incoming interns to think about this as a new critical problem and to perform a full workup that encompasses all the most-likely things on that differential for that problem.
That involves, first, going to see the patient, which you guys probably have already heard multiple times. Get a full history, so discuss the nature of the nausea, time course, severity, things that make it worse or better and just overall a full history of their symptoms because you never know when one of these questions is going to drastically change your assessment and it takes so little time to do a history that it's really hard to justify not taking a detailed one. Next, perform a thorough physical exam. In a patient who's vomiting postop you might be included to just perform an abdominal exam, but really you should include other components, and again, the small things will change your management.
And then finally, think about whether or not you actually need additional labs and imaging. Sometimes people get into a mode where they reflexively order a new set of labs or abdominal film for all patients who have nausea and vomiting, but think critically about every new clinical scenario and about whether those are actually going to change your management. The second one is to actually spend time with the patient. It's really easy to sit in the work room and type up your notes and get your discharges done, call your consultants and have a little time for coffee, but what-- what I didn't realize until later in my intern year was that the intern actually has the most time to spend with patients and that patients really need that time to feel comforted, educated about their care plan, understand their instructions so that they can actually affect their own recovery.
The chiefs are blasting through their morning rounds, they're running to the operating room, seeing consults, staffing with attendings, making their M and M presentations, writing papers and all sorts of other things that you don't see as an intern, and all these things really put a strain on the ability for the chief to actually spend time with the patients. Functionally, I actually accomplished this by going to see the patients after p.m. rounds, even if I saw the patient with a chief, and spend time in each patient's room discussing whatever questions they have until they're satisfied.
Sometimes this can be really painful but I really think it makes a difference in both motivating patients to further their own recovery, as well as satisfy them with respect to the communication with a surgical team and that can save a lot of pages and heartache later. >> Yeah, Craig, I couldn't agree more with what you said, and I think those kind of go together in that I think also too from what you were saying is-- is something may become a problem for interns as they get comfortable and later in the year, you get a page with the same complaint, you said, oh you think this is just an ileus or kind of a knee jerk response or-- for us as senior residents, if someone says, oh this is a consult for xyz, you say, okay, this is easy, I know what to do.
But until you actually see that patient and really think about what's going on and consider a full differential, like you recommended, I-- you'd be shocked about, you know, how variable patients present or how unique their individual problem can be. And so, I agree, thinking critically about each patient, seeing the patient, and then-- and then obviously for your second one, spending time with them and making sure they're-- they're comforted and educated and know the plan that everyone's setting forward is huge and it's hard.
Like you mentioned, on morning rounds, they go by so quick and you're trying to rush to the OR to spend five minutes or less in each patient's room, to have an intern go and say hello and check in and make sure the patients are happy and clear on what's going on, that's-- that's huge, and it's huge for the attendings, it's huge for your chief residents and people appreciate it immensely. >> Alright Val. >> Last but not least. >> You're up next. What do you got?
>> Hey guys, this is Valeria. I re-- I'm so excited to be her. Actually, I've been listening to BTK since I was an [inaudible] and I still remember emailing Kevin to get one of those BTK pins; I still haven't gotten mine [laughter] but I have-- [ Inaudible Response ] I have a-- I have two pearls that are kind of a little bit more actionable and the first one is going back to my actual-- my very first call as an intern on nights on ACS when Patrick was actually my chief and I was late to print the list because 100 things did happen and kept me from getting that on time.
So, the first thing that you should think about as start in the wards is that you shouldn't underestimate-- overestimate the time that you have in the mornings, post call to get ready for rounds, and that's not just the list. If you're lucky enough to catch a few hours of sleep you should plan ahead for all the things that are going to delay your pre-round workflow and time you wake up to that. If you happen to be busy during the evening, and unless someone is really sick and you're actively at their bedside there's really not excuse for-- to not have everything ready for the day team to round and get to work.
They really rely on you to get the day going smoothly. And so, if you teach yourself to update your list on the go, be mindful to order, the order that you arrange your patients for rounds, you send and review li-- labs in a timely manner and you set enough time aside to print your list in the mornings then you will be set up for success. My second pearl is more along the lines of what Ryan was saying initially, being kind to everybody. You should not assume that the obvious to you is obvious to everybody else in the care team.
It's very easy as a junior doctor to be very self-centered in your workflow and assume that everybody is online with the things that you are thinking for the care of your patients overnight and interns sometimes get clamped when patients complain and the nursing doesn't know the importance of keeping them going, and time critical drug levels sometimes get drawn after drugs have been given and then in the morning they're like, the [inaudible] level is elevated and the patient received a dose. So, if you utilize your communication skills to impart some of these things about the management that are a little bit more, sort of, oriented to the rest of the members of the care team you're going to find yourself saving yourself some pages and some heartaches.
And on the same way, you should never assume that you know what other people's jobs are; from the nurses to the techs, to the attendings that are leading the care of your patients, let them teach you what is important to them. So, asking the nurse what order-- what orders they want or when you order a test and the tech is not able to get to the patient in time these are important things to keep in mind as you're moving forward, you're working as a team with other people. >> Wonderful. So, thanks Val for those insights. I think time management is something that's critical in during your intern year and you've done a great job throughout this year showing that you really have a good sense of how to manage it.
Secondly, I think communication with all providers, including nursing, ancillary support stuff is really important because it helps, sort of, frame the goal that the team has for the patient. So, with that said, why don't we move on and start talking about how interns can be more effective and organized during their regular schedule. We'll start with Dr. Ryan Eton. Why don't you tell us a little about how you've, sort of maintained such an organized workflow during your intern year?
>> Alright. So, point number one, intern is only as good as his or her pen. So, you need to write absolutely everything down. Do not-- if you think you can remember everything just forget it. You need to just get a good pen, your favorite pen, multiple colors help, have them in your white coats, and basically everything that your chief resident says and any information that you learn from the charts, vital signs, exam findings, imaging findings, labs, orders, you need to write it all down on a piece of paper; I promise you will not remember it, okay.
So, your job is essentially to be the most detail-oriented person on the team. You have to account for every tree in essentially a massive forest, so there's just too much to remember. To give you, kind of, an example, I mean if you forget one Lasix order, for example, your-- your patient might not meet his or her diaresis goal for the day meaning they won't be weaned off of oxygen, and they might need to stay in the hospital that day. So, the point of this being that failing to stay organized and be on top of plans for the day can have real consequences for patients.
Number two, and this was something that I learned maybe halfway through the year, when I was going to be on-call overnight for my service, and there would be postoperative patients admitted to my service overnight, I made a habit of the night before reading up on their charts and getting familiar with their co-morbidities and their stories and the reasons why they are going-- undergoing this operation. The reason this is helpful is that your chief resident is going to page you in the [inaudible] to tell you know, how the operation went and what the plan is.
They'll give you a one-liner on the patient, but to be honest with you, you know, the chiefs are very busy, they're heading into another operation and they need to tell you a lot of information really fast, and if there's one thing that they sometimes won't be completely comprehensive about is just the patient's co-morbidities past medical history, and so it's-- it's super helpful for you to know if this patient has heart failure, CAD, if they've had a cabbage in the past, because that's going to keep you on your toes overnight if a patient, you know, has a lot of co-morbidities.
So it's-- it's just-- it shows that you're dedicated, you're a good team player and that you're prepared, and your chief residents will love you when you say, hey, you know, Patrick, I already know about this patient, I'm familiar with them, go ahead and just tell me how the operation went and what the plan is and they'll love you for that. >> Yeah, I couldn't agree more, and I think all four of you guys have done this, and there's nothing more impressive, honestly, I mean there's some things more impressive, but this is one of the more impressive things is you get out of the OR, you just did a long case, [inaudible] getting ready for the next one and you're about to sign this patient out and they say, oh yeah, you know, I know about the congestive heart failure and about their Lasix that they're already, etc. etc. I mean that's huge and-- and it's not only critical for that intern or junior resident who is taking care of the patient to take good care of the patient, but it also, like you said, it just-- it makes your chief, attending, etc. everyone feel better that you know what's going on, you've prepared, and it takes off a ton of stress when you get five admissions in the middle of the night and someone else is sick and you already know when that new admission comes in, you already know what their history is, I mean that-- that's a huge stress reliever for you as you take care of them.
And then, yeah, you've got to write everything down. There's just no way. It's insane to try to think. It's-- I think Craig was telling me this-- his analogy one time that you go to a restaurant and maybe it's not the fanciest restaurant but the waiter or waitress is going to play cool and remember everything in their head and the inevitably forget some-- something-- some part of your order, right; they're not writing it down. And so, yeah, that's-- I like that analogy, but you got to write it down, there's no way. So, I think those are great, those are absolutely great points.
Glen what do you got? >> Hey, so I have two things. One, the first thing I said, there's like no perfect method of staying organized and being an efficient intern. Different people are going to do it different ways. What I found actually was the most helpful thing was when I was a sub-i I saw-- sought out the interns that I thought were really efficient and slick and I asked them their system, or even the second years, which are basically interns with a year of experience, and asked them how they stayed organized.
And, you know, I picked a method that sounded like it fit my style and I'd pick one that sounds like it fits with your style and I would just keep with it, because honestly, the more you do of it the better you'll become. The real trick of being an effective intern is not to be lazy. If you are active and work hard everything you'll do you'll become effective. And then the second thing I wanted to talk about is the workflow, workflow of the day.
I think what's always best is to do orders first, consults, discharges, and then get to the other stuff in notes. The real key on your workflow is to not get distracted with pages. You'll learn very quickly, outside of codes, floor emergencies happen over the span of minutes and not seconds. So, if I'm writing an order on a patient and I get a page I finish putting in all those orders on a patient before returning the page. And, I think, where people run into problems is they got bogged down with the minutiae and they're trying to answer every page in a second and they get distracted and like tasks get lost, so I think it's better to fully complete three tasks than half complete 12 tasks, because that's how things get dropped off.
>> Great. Love it, Glen. Seriously I do. In terms of identifying what others have done well, especially when you're going to be assuming that same exact role is key, not trying to reinvent the wheel and trying to figure out a new way of doing things, there's going to be tons of great examples of good interns and good residents at every institution, so just find the people that have been successful, talk to them, and get a sense of what they did, and pick and choose things that you like from other people's, sort of, workflow, and then sort of apply it to yourself and the next thing you know you'll be one of the best interns as well.
So, with that said, let's move on to the next topic and it's a really important one, especially since we're here on Behind the Knife talking about, sort of, educating the next generation of surgeons. Let's talk a little about efforts that our residents can make as interns to teach medical students. So, let's start with one of our best surgeon ed-- educators, Craig Brown. Let's hear what you do whenever you're working with medical students on service. >> Yeah, thanks V. I think that teaching medical students accomplishes a couple things in my mind.
One is that obviously it provides them with education, which is part of your job as a resident, frankly, but the second is that it forces you to learn the material in a much more in-depth way than you otherwise would, because of the questions that they'll ask when you're teaching them. Richard Feynman was well known for his belief that if you can't teach even advanced concepts to absolutely anyone it's because of your lack of understanding and not theirs, and I think this absolutely holds true for medical student teaching and medical concepts as well. >> The other thing that is very important for you to start thinking about, because everybody wants to teach and feel like we all went into medicine because we have a love for taking care of patients and teaching others and learning.
However, once you become an intern you will-- you will take on another 100 jobs, so in the rush of your days it's always easier to forget about the med students and get your work done, and this going to be like the immediate thing you're going to notice and, however, this is absolutely not acceptable and you have to get yourself in the mindset that you're there to take care of patients first and then to teach second. So, I started to set up an agenda, especially in the really busy days. I will let my medical students know that I have to sit down and put orders and write notes for whatever amount of time I need in the mornings, especially if they don't have assignments for the day and they're just kind of looming around trying to be helpful, and then I will tell them at this time we're going to take this drain out, we're going to take this [inaudible], we're going to go through an oral boards case or review whatever notes that have written for their patients.
And then when-- in doing the op in the OR is actually, kind of, my favorite teaching stage, which is plus and minus hated by some residents because you're-- like you're trying to get the next patient and the next case in but it's actually an invaluable opportunity to do some feedback. So, once I'm done putting in my postop orders and I have my medical student with me I set the stage by telling them that I'm going to give them some feedback and this always takes them by surprise. And then I take about three to five minutes, so very short, to point out two good-- two things that they did well, either answers that they gave, or technical things, and then two things that they can work on for the next time we operate together.
>> Yeah, I absolutely love what Val said and it's-- what that is is very deliberate teaching, deliberate feedback, deliberate, deliberate, everything's deliberate in that you include the medical students in everything you're doing. So of course you're busy, of course it's hard to fit in the time, but you either schedule the time, you make the time, or maybe you even can't do that, but as you're running around, seeing the next consult or you're putting your orders in or you're getting ready for that case just talk, talk out loud, talk about what you learned and especially as junior residents what you're learning and what you're thinking about is super highly relevant to medical students because you're just-- you're closer, closer and closest to them and what they're learning.
And that-- and it helps you too; that's exactly what Craig said; if you can't teach it then you don't know it that well. And so, it's-- it's huge, it exposes, kind of, holes in your analogy. Be like, oh, let me sit down and tell you about this topic, and that if you kind of fumble through for five minutes you go, oh man, like I didn't really know that as well as I thought I did. If you can get that honed down to the point where you're-- you're reliably giving good information to medical students and they're peppering you with different random questions and you can answer them then you know the topic and its-- it's-- it's pretty-- pretty huge.
And so those are absolutely great pieces of advice. And so, regarding that, kind of similar, we're going to move on and talk with Craig again and then Glen about how you studied and which resources you used and what you thought was most useful and we're going to talk about, kind of, some core surgery concepts, prepping for the OR and of course, studying for the ABSITE. So, Craig, why don't we-- why don't you come back. >> So, studying for the ABSITE for me was really just about score questions.
I really didn't read any textbooks, I just tried to rip through as many questions as I could, and I think making a daily small commitment, like even 10 or 20 questions is a great way to stay on track and not get overwhelmed at the last minute. For the operating room I think I read more-- I read more now about patients than I ever did as a medical student, and that being said, you really just need to have a good understanding of the indications for the operation. A basic understanding of steps of the procedure, and then the expected postoperative pathway. The other point that I want to make here, too, is that a great way to prepare for the operating room for cases I think later in the intern year and even as a PGY two and three is to double scrub everything that you can because that really gives you some insight into the way that the attending does the operation without the, sort of, stress associated with preparing for being the surgeon junior in that case, and it can be a great way to get some experience and exposure to the attending as well.
>> Great. So, Glen, why don't you share with us some of the things that you've learned throughout your year. >> Yeah. So, I'll kind of go in reverse order of Craig. For the operating room I watched like a lot of videos, you can Google them, and also like web search videos. And then reading like Atlas as a Surgery, I mean, we're here at Michigan so I'm particular to operative techniques and surgery, that's a Michigan textbook. But any-- any-- really any textbook will have the steps surgery just as long as you take a look at it and you try to get the steps down ahead is probably the best thing for the operating room.
And then I can't stress enough what Craig said about double scrubbing; that is the best thing to do to get ready to do cases and just writing down as many notes as possible when you do double scrub cases. And for the second part about ABSITE, I think ABSITE, like almost anything there is a million different things to do and a million different ways to study. One of-- the thing honestly, I did the most and most consistently was listen to Behind the Knife. I mean it's the easiest thing for me to do when I was driving into work, driving home, and then also while working out and you could do that yearlong and it makes you feel good like you're studying all the time.
The other thing is, like, so similar to Craig, I-- I'm a big question guy and so in addition to score questions I read there's a question book DiVirgilio [phonetic] that I did. There's a ton of other resources and I know people that use them, just those are what I found for me, and I think the best thing is, like everything, is just find a couple things that work for you and just stick with that. It's not trying to read every single book that everyone ever recommended or do every single question from every site that's recommended. There's more than one way to skin a cat for sure.
>> Great. So, thanks Glen and Craig for, sort of, sharing your wisdom there. In terms of daily preparation and, sort of, doing a little every day I think it really amounts to a lot, whether it's learning from your patients as well as preparing for things like the ABSITE, none of these things can be done in like a short period of time, that's why training is so long and that's why it takes so many years to become a well-trained general surgeon. Also, I think learning as much as you can from the operating room, from others, like by double scrubbing, is a really nice way to, sort of, learn.
I've seen both of these guys in the OR throughout the course of this year, double scrubbing some of our biggest cases just to sort of see how the retractors are set up and how the faculty is providing exposure during the case, and sometimes when you're the person that's, you know, tying of the vessel, you may not notice all the other things that are happening around you, so great advice there. Alright, so we talked a lot-- >> Hold on, before you say that I got to throw in the love fest here for all the work that the BTK guys here are doing regarding ABSITE reviews; those were just phenomenal.
And so, year-round listening, like-- like Glen said, is a great way to stay up to date on things and you can do it any time. >> Absolutely. >> I listen to all the episodes. >> Me too. >> The ABSITE. >> It's so interesting because when people caught up onto it over the last year, I had listened to like the original, the like circa 2013 ABSITE review and I was like oh-- I was like have-- been there, done that, listened to that.
>> So, Val, you're a long-time listener, first time caller. >> I am. >> It sounds like. >> Yes, I [laughter]-- that's always the-- I'm always the lurker [laughter]. >> Alright, so-- so it sounds like we've talked a lot about what you can do to be successful by preparing for the hospital and, sort of, your cases and the various exams that you'll be given as a resident, but a big part of being a happy resident and a successful one is having a life outside of the hospital as well. So, Val, could you talk a little about some of the things that you've done outside of the hospital or in life in general to try and maintain sanity during a very stressful intern year?
>> So, before we step out of the walls of the hospital I want you to bring you all back to the hospital just for one minute because you're going to be spending a lot of time taking 24 hour call, and for me, to be able to stay sane at home I had to be able to set up the stage during my call shifts to make sure that I was a functional human. And so, I-- I was just talking to our new interns recently about this and how to have a productive call shift and 24 hours-- working 24 hours is a great-- very great learning experience in taking care of patients, but it also can be exhausting.
So, I gave them-- gave to them the analogy of finding your shower, and this is my personal analogy and it goes back to my particular preferred way of resetting during call. So usually during call you will be staying up late, usually working on patients, taking care of things, putting out fires, and then there's going to be many calls in which you will get no sleep, but then there's going to be a lot of calls in which maybe your floor's quiet, you tucked in your patients, you checked on all of them and you get a couple of hours of sleep. It is really hard to sleep in a hospital, at least for me, although many nights I will have the opportunity I didn't get enough rest so I started-- I started taking showers.
So, I found where all the showers in the hospital are. If you need to find a shower at the University of Michigan I know where they are. I'll take a quick shower, I'll change scrubs, I'll brush my teeth before running my midnight vitals, and I know it sounds super silly but it made all the difference. And because of the showers I started to have these conversations with my co-interns and my co-residents about what they did during call, and since then I have heard about all of those different strategies to keep it together during your 24 hours, all of their personal showers, and here's some awesome ones; this one is from one of our rising [inaudible], Dr. [inaudible] brushes her teeth the correct amount of times in 24 hours [inaudible] and I started doing them myself.
Also, sitting down to eat dinner. I have had many dinner parties with my co-interns; we'll find who's on call and we have 30 minutes to sit down and eat a meal. Finding a workroom with people in it, if you're really busy, can help. Also walking outside between buildings is our chairman's favorite thing-- thing to do and it was his piece of advice when I was just starting, to get some fresh air when you're on call, playing some music if you're up late getting the list ready, and also making some time to eat breakfast before rounds is something some of my co-residents do.
>> Awesome. Well that's amazing. Michigan, home to the best smelling interns [laughter] in the country. Alright, so-- >> Where a single shower is [laughter]. >> I do, I do. Okay, so now I'll give you the life advice; people are going to talk to you about exercise and healthy eating and family and friends and we should all be doing that; those are excellent things to do, but I also think that the smaller life choice are the first things to go when you're a busy intern and I will argue that you-- those are the ones that you should keep the closest as you get this year.
And [inaudible] video games and also whatever Netflix show you're watching, getting-- making time to online shop or get a massage or a manicure or go to a soccer game or get a beer or a meal with friends. For me, it was my dog. I do have a dog and you can do it. I spent a lot of time and mental energy keeping her alive and healthy. I also planted a garden for whatever reason and I spent time doing that. So, find whatever gives you joy and gets you into a happy place and try to do that semi-regularly.
>> Great. Ryan, what about you? Any advice for keeping it sane during intern year? >> Definitely. So, number one, vacations are for relaxing. Do not feel obligated to write that big paper or take on project during your only week off in three months. You do not and you should not feel guilty for sleeping in or just completely checking out. I think my favorite vacation this year was when I went to Florida and just went to the beach every day, you know, didn't answer emails, basically, did nothing for a week and came back fully rested and ready to come back to work.
Number two, calling your friends and family, I think is really important and really easy to forget. A lot of you who are moving to a new city, you're going to be meeting new people; I did that. It can be pretty lonely when you don't know anyone in the city, so just make sure to stay in touch. Don't forget about your high school, college, medical school friends and the family members who I promise want to hear from you and-- and you should really make it a priority to call whenever you can on your way home from work, whenever.
Number three, speaking from perspective, I'm married and I have a-- you know, my wife at home and she's also a resident, and one piece of advice about-- for those of you who have significant others, when you go home make sure to not be-- don't be lazy. You're not lazy in the hospital, you shouldn't be lazy when you go home and you shouldn't be putting extra work on your significant other; you should be contributing in an equal-- equal way, and that's going-- that's going to be very helpful for you.
>> Yeah. >> Sorry, can I add just one thing? >> Yeah, please please please. >> Like, I thought what Ryan said was beautiful and like, just in general, just know you don't get less busy. So the people who start intern year and you're like, oh it's super busy, I'm just going to hold off on these things and then later on I'll pick them back up, like you never get less busy, you only get more responsibilities in the hospital and then at home, so that's like a fallacy; you've got to make time for all those things that Val and Ryan had mentioned.
>> Yeah, so many good recommendations and key to staying happy and healthy and productive at work too. And there is not that much time and so you have to identify that time, schedule that time, plan for these things that make you happy and you enjoy and that can be challenging and it takes-- I would definitely say, as an intern, it takes a number of months to figure out where you fit in that meal with your significant other, you know, where do you fit in that workout, do you sleep more, do you work out; what-- what-- how do you-- how do you manage these things?
And you'll figure it out and it just takes some time. So, in those first few months when you're tired and stressed and the learning curve is so so steep remember that while you don't get more time later, necessarily, you get way better at managing it and recognizing it and getting into your own-- your own rhythm and kind of your own flow, so-- so make sure you know that's coming. Alright. So, let's-- let's ask one last question of all of our esteemed panel here and we'll start back, right back with you, Ryan, and we're going to talk about looking, kind of looking back, reflecting on your first and or second year of residency and trying to identify something that really powerful that you learned or something that you recognized you'd want to do differently in the future.
What do you got? >> Sure. So, I would say that intern year doesn't have to be terrible. I actually had a great year, right. I love the University of Michigan. I love this place, I love the people that I work with and-- and I'm thrilled to be here and a lot of people come in to this year understandingly very nervous and you will realize after a year that you actually really love your job, you really love taking care of patients and you'll-- you'll be happy, so, kind of, just giving you a life lesson there or a take-away is just I'll just say that you're-- you're surrounded by people who want you to succeed, and that goes from the chairman of surgery down to the faculty and your senior residents, your co-residents.
Everyone is going to make themselves available to you if you need help. I would also say staying humble helps. The culture of surgery is changing but there's still a hierarchy there that requires you to spend some time at the bottom of the totem pole, that's still the case and, you know, you will one day soon enough get the chance to operate and you will one day not have to write those discharge summaries and those Dulcolax orders. So, for now, just embrace your role, try not to complain.
I think that if you-- when you do complain, try to complain to your co-residents; don't gripe up the ladder, your chief residents have too much on their plate to listen to you complain, to be honest, so you should really just put your head down, work hard, stay positive and you will-- you will thrive your intern year. You made it here, you belong here, you know, keep your head up and you'll do great. >> Awesome. Thanks Ryan. Alright, so Glen, what about you? Anything that you learned or what ifs or what I should have done or what I shouldn't have done over the last few years?
>> Yeah. Yeah yeah. First thing I-- I'll echo Ryan; intern year is amazing; it is infinitely better than being a medical student. >> Oh yeah. >> So. >> Hundred percent [laughter]. >> You can have the worst intern year and I'm telling you it's better than being a medical student. So, the one thing-- the one little piece of advice I have is that I wish intern year I would have taken more notes in the operating room.
I feel like whenever I double scrubbed, I was just so happy to be in the operating room and like tying a knot that all the time, especially when you're a junior resident, especially when you're intern, people want to teach you all kinds of little things and, you know, in my head, at the time, I'm like of course I'll remember this. So, you know, like this is the chairman of surgery just gave me a bit of advice on holding an instrument or setting a case up, like there's no way I'll forget it, but like you completely will forget all these little things [laughter]. And so, if I had to go back and do it over again I would, after all these things that I learned, small little things, I would have wrote them down so I could remember them.
But it's a seven-year program so I'll get-- I'll get another shot at it. >> We won't tell Dr. [inaudible] that you can't remember what he said [laughter]. Alright, Craig, what about you? What about some things that you can, sort of, reflect on over the last few years? >> Yeah, really-- I guess really the only thing in-- you know, for me, is this sort of managing expectations for incoming interns. When I came in, a huge source of anxiety for me was handling the pager and what it meant to be the first responder to a page.
I think my expectation was even the first day we took call was that every single page was going to be an absolute disaster. Every patient who I got a page about was having a new MI or having a PE or coding or whatever and so I thought I was going to be running around the hospital coding patients all night long, and the reality is is that 99% of the pages that you get are actually order needs updating, patient would like Colace, patient's family wants birth control restarted, despite being intubated and sedated.
Like there's a lot of things that happen that you get pages about that are not super important and are not acute and I think that once you realize that point, the taking the pager and holding the pager becomes much less anxiety provoking, and therefore your call shift is much less anxiety provoking, I think that's a big point. >> Alright, sweet. Those birth control pages in the middle of the night are challenging [laughter]. Valeria, what about you; any insights? >> I-- I'm going to actually echo some of these that Glen said because I actually started-- I created this system because it was a piece of advice, writing things in the OR, was something that one of my chief residents when I was a sub-i told me and I was like I'm totally going to do it.
So, I started making these preference cards on the Evernode, or whatever your favorite flashcard app is, for every attending I started operating with early in intern year. It'll have like name of the attending and the operation and just the things, the little pearls that they sent me. Mostly OR set-up and where they like their ports and how they like to close and stuff, and you know, it was great until I fell off the wagon. Another thing, you will fall off the wagon sometimes with these things, especially studying and other important stuff.
And then when I rotated back in services, like not too long ago, I found that whatever notes, whatever little stuff that I had written up was actually super useful. So, I know that it's hard-- you're like nobody keeps journals nowadays and you're like while will I write things down and will I ever look at them, you will. I had them on my phone and I came back to this same-- this one faculty member, same operation, I looked at the notes and I had the setup down. And I recently got to update like my very first card with new attending preferences and actually added on onto them, now they're management points that I actually understood now that I'm getting out of intern year.
So, I wish I had kept up with that little deck a little more, but again seven-year program, so I'm planning on doing my best to do that the coming year. >> That's awesome. These-- these have been really great points on all these questions. And so now I get to bounce it back to my co-resident, the good Dr. Nikolian. We're going to give-- each of us are going to give a couple of our thoughts on-- on how interns can thrive. >> Are these your quick hits? >> Yeah. Yeah, these-- these will be the quick hits for this one.
>> Yeah, exactly. >> So, V, what do you have? >> Alright, so first and foremost, I want to thank all the residents that joined us today to sort of discuss and to share their own insights. I think it was wonderful for us to learn from them. I'm listening to them talk about what they wish they knew and thinking to myself, man, I wish I knew it myself. So, you guys rock. Thank you for joining us.
So, in terms of some pearls and wisdom, someone that's been doing this now for approaching seven years in training, I wanted to provide just a few, sort of, things that I learned over the years. First and foremost, I think, prepare for the things you can prepare for. So, residency may seem like we're always running around, sort of making plans on a whim and not really planning our days effectively, especially as a medical student; you may feel like, wow, the chief knows everything. Well there's a reason why the chief knows everything and why many of the residents on service know everything, it's because everyone takes time to prepare for that day.
Whether it's preparing for your case, preparing and reading about the patients that are coming into a busy clinic, or thinking about your next education conference and how you can prepare to, sort of, ask insightful questions, these are things you can do as a resident from day one to demonstrate that you're thoughtful, and also maximize the education you get while you're inside the walls of the hospital. Number two, this is a statement that a lot of Michigan residents know, it's plastered on some walls all around the campus and it's that practice doesn't make perfect, but perfect practice makes perfect, and that's really important.
When you're practicing a surgical technique or when you're practicing something as simple as a knot-- a suture technique or a knot tying method you need to practice in a setting that's conducive to translation into the operating room. So, don't necessarily tie while sitting down and tying to the drawstring of your pants you're never going to tie in that position in real life; you should stand up and do it just like you would do it in the operating room. You'll translate into a better surgeon.
Three, seek and apply feedback, and this is really important. Nowadays, all of us want more and more feedback, but it's really important to seek it out, and when it's provided to you really be thoughtful about it and try to apply it for the next interaction with that person or when you're taking care of that next patient. Really learn from the opportunities that-- or the time that someone else takes to teach you and try to become a better doctor because of it.
And finally, plan your time off. Just like Ryan was talking about, you're not going to have a lot of time off as a resident, but I try to make the most of it, whether it's planning a weekend trip with my wife or making a nice European destination trip that we'll sort of plan a few months in advance. Those-- those planned events translate into time that I'm already thinking about an exciting time in my life, and oftentimes mean that when I come back to the hospital people are asking me about my recent trip, it really turns into about two or three months of excitement for a single weekend or a single week away from the hospital.
So those are my pearls and I'd love to hear Patrick's. >> Those are-- those are good; that's like really good; I don't know that I can follow up on that. I'm going to start by dovetailing off, seek and apply feedback; that's absolutely huge. And this is something that you can be very deliberate about, especially as an intern or a junior resident, any-- any-- in-- throughout residency. You go to the OR, before the case starts, you say I'd like to focus on this part of the case, you know, you T it up for your attending.
They know exactly what you're looking for, they can give it to you. After the case, in person, right then and there, ask for specific feedback, not just any feedback, specific; how did I do with throwing my-- doing my slipknots? Very specific, very pointed. You get that feedback and embrace it, really take it and try to improve. You know, that-- it's-- it's-- that's probably my num-- definitely number one, that's why, I think, V, that was a great one.
Details. So, a number of these guys have mentioned it, details, details, details; pay attention to those details. You get the orders, you look at the ins and outs, new lab results, patient-- patient vitals, etc. etc. etc., it goes on and on. And as the junior, that's your job; you are taking care of these patients; you are the front line; you need to know these things and it makes for good patient care and so you have to be very detail oriented and it's hard; you have to stay organized to do so.
It's mentioned multiple times, double scrub cases, you could learn a ton, you get to do a ton. People will throw you big big bones when you're hanging out, checking things out and learning how to do those cases, and when it comes time to do those cases, you'll be great at it. Looks good for you, it's fun, it's better than hanging around doing nothing on the floor. Double scrub those cases. And these guys also mentioned using your-- your-- your brand or product of choice. I use Box.net, similar to Dropbox; its easily accessible on my phone and I can choose different documents I can save for use offline, but every time I finish a case where they'll mention a specific patient or attending preference or setup, I'll-- I'll write it out.
If it's real detailed I'll put it in a Word document and put it in the thing or I'll flip over my list for the day and draw a torso, put where the ports are going to go, talk about which order this attending likes it going, which staplers I get to use, etc. etc. and I took a picture of it and I email it to myself and then I upload it straight to my-- my Box.net app and I can pull it up whenever I want, and that is-- you talk about forgetting things, you'll do a case through-- you'll do a whole month of call back until you know how to do [inaudible] perfectly. And then six months later, when you get back on rotation, you're like, oh man, I absolutely forget everything and you can pull up your own notes that are half a page long you'll be right back in the game really quickly, and so that's huge.
As a junior, think think think all the time about how you can be helpful and multiple of these guys who have joined us today do this, and I am always very impressed by it and surprised and-- and happy. When they think about how they can be helpful, maybe that's just putting in orders during rounds when you don't have to, ensuring the dressing supplies are available, the little things, writing admission orders. When you scrub-- double scrub that case and you're not doing anything, scrub, oh hey, I'm going to put in the brief op note; that's huge; that's absolutely huge.
It's just when you go out of your way and you think about other people, they're going to start thinking about you. And so, my last one, this is something I thought what was the single hardest or most annoying part about intern year and it's those moments when you're sitting there and your pager is just blowing up and, you know, you're getting harassed about a discharge document and orders that mean nothing and you have literally 25 notes to write and the phone is ringing and I've had, you know, you've had times where literally you're holding two phones up to your ear-- each ear; that happens, and that can-- that hurts; I mean you can get real wound up, you can get really worked up about that and-- and I can't remember who mentioned it but Gr-- Craig mentioned.
That's not the-- most of it doesn't matter, frankly, you know, patients aren't dying and sometimes they-- if they are dying then you got to get-- you know, get moving, but most of the time that's not happening and so you can stop, take a big deep breath, realize that everything-- that you will get through all this stuff and it's amazing sometimes how quickly you get through it, even though it seemed uncer-- [inaudible] at that time, do that because this will happen many many many many times and you just want to chuck that pager against the wall. Just stop, take a big deep breath, and recognize it's all going to be over pretty soon.
>> Alright, so thank you Patrick for those pearls and some wisdom from a seventh-year resident here at the University of Michigan. So, with that said, I think that does it for today's episode. Next week we're going to have a much more hard-hitting top-- hard-hitting session where we'll be discussing difficult clinical scenarios for interns. >> Great, and as always, feel free to email V or myself at the addresses listed in the show notes. We love hearing from you all and that's how we came to do this episode is based on listener recommendations.
And so, until next time, take care and dominate the day. >> Until next time, dominate the day. [ Music ]