As an intern, I take days one at a time. Once in a while, I'll actually look a few days ahead and plan to do something fun on my day off. However, I rarely look much further in the future. One of my medical students was bemoaning that the school was asking them to put in schedule requests for their rotations next year. It does seem difficult when you've only finished half a year to figure out what you want to do the next year, especially when these years are supposed to shape your future career. I told my medical student to suck it up because it doesn't end. I just submitted my schedule requests for the 2008-2009 year.
Filling out that form was mind boggling. When do I want to take vacation next year? I had to email all my engaged friends and ask if they were planning weddings before July 2009. When do I want to be in the ICU? Which ICU? What about electives? What do I want to be doing on July 1st? That's when I'm a brand new resident with brand new interns. I'll be a resident in less than six months!
Luckily, I'm on emergency coverage now with more than average free time. (Thank goodness my co-interns haven't been inflicted with that raging diarrhea that's going around.) So, I was actually able to step back and look at myself. I found that a lot of me is the same. I still want to spend vacations with my husband when he's on break from school. I'm still interested in outpatient medicine despite the copious amount of time I have spent in the hospital this year. And I'm still terrified that I will make a mistake and kill someone. Those were my guiding principles in filling out my requests.
What's changed about me? Less than I thought. While I'm on the wards or in the ICU, time is limited, so I don't get to indulge myself in my hobbies. Yes, spending time cooking or watching TV seems like an indulgence. (Luckily the writers' strike is making it easy for me to stay away from my television.) However, now that I have more free time, I have found happily that I am much the same person that I remember I was. And I'm relieved. Yes, I've changed as a clinician, but I'm still me.
Monday, January 21, 2008
Is the silence deafening?
So, it's been a long time since I've posted. I've started a bunch of entries, but in the end, I justified my long pause between posts by saying that the silence was saying a lot.
The greatest skill of an intern is the ability to prioritize. There's always lots to do each day. After rounding each morning, I think, "Should I write my notes? Go to morning report? Call my consults? Put in orders? Teach my medical students?" The ranking of priorities extends beyond the walls of the hospital, too. A few weeks ago, my car ran out of gas. That's never happened to me before, but time is limited. On my list of priorities, filling my car with gas was probably lower than it should have been. However, getting home to spend time with my husband is pretty high, and the gas would have been helpful in getting that task accomplished. I'm still learning how to prioritize, but on the list of priorities, this blog is somewhere below filling my car with gas.
The greatest skill of an intern is the ability to prioritize. There's always lots to do each day. After rounding each morning, I think, "Should I write my notes? Go to morning report? Call my consults? Put in orders? Teach my medical students?" The ranking of priorities extends beyond the walls of the hospital, too. A few weeks ago, my car ran out of gas. That's never happened to me before, but time is limited. On my list of priorities, filling my car with gas was probably lower than it should have been. However, getting home to spend time with my husband is pretty high, and the gas would have been helpful in getting that task accomplished. I'm still learning how to prioritize, but on the list of priorities, this blog is somewhere below filling my car with gas.
Tuesday, October 16, 2007
The Intern 15?
At our recent intern retreat, our program directors took the liberty of flashing a picture of each intern in a slide show. Most of the pics were taken from those submitted with our residency applications, and we just had to laugh! We all look so different. Shiny, happy, and new in our best suits. Now I'm wearing T-shirts over drawstring pants covered up by my greyish white coat.
After the slide show, two people commented to me that it looks like I've lost weight since my picture, and after weighing myself (finding a scale in a hospital can be surprisingly difficult), I found that it's true! While my friends have been moaning about the "intern 15" as equivalent to the "freshman 15" gain in pounds, I've been losing weight. I guess it depends how you deal with stress, and for me, I usually can't relax and eat until all my work is done. That means I've missed a meal here or there, and I rely a lot on snacks in my pockets, mostly granola bars.
However, I just started on a new wards team, and there's food everywhere! Munchkins! Candy bars! Pumpkin-shaped cookies with frosting! Maybe the "Intern 15" will be in my future!
After the slide show, two people commented to me that it looks like I've lost weight since my picture, and after weighing myself (finding a scale in a hospital can be surprisingly difficult), I found that it's true! While my friends have been moaning about the "intern 15" as equivalent to the "freshman 15" gain in pounds, I've been losing weight. I guess it depends how you deal with stress, and for me, I usually can't relax and eat until all my work is done. That means I've missed a meal here or there, and I rely a lot on snacks in my pockets, mostly granola bars.
However, I just started on a new wards team, and there's food everywhere! Munchkins! Candy bars! Pumpkin-shaped cookies with frosting! Maybe the "Intern 15" will be in my future!
Friday, October 5, 2007
Starting at the VA / Winning the game!
I'm about three weeks into my rotation at the VA, and at first, it felt like I was starting internship all over again.
Being in a different hospital means many things are different. As an intern, it's my job to get stuff done--tests, labs, consults, etc. If they don't get done, I see it as me failing at my job. Patients staying extra days in the hospital means higher risk for hospital-acquired infections and complications, so all around it's frustrating for me and somewhat dangerous for my patient when there are delays in diagnosis and therapy.
The VA computer system is regarded as one of the best if not the best in the country. However, if you don't know how to fully utilize it, it can be a complete disaster! Although I did a rotation at this hospital as a medical student, I wasn't familiar with all the steps it takes to get things done. It was taking me 30 minutes to figure out how to order regular finger sticks to test blood sugar levels on a diabetic! There's also cultural things about each hospital--which antibiotics they tend to use, availability of certain imaging, consults, and pharmacy rules. If you don't know these things, you'll definitely be less efficient.
However, I'm on another great team, and we all helped each other out as best we could. My first week was plagued with late nights cursing the separate menus on the computer system, and I would come home every night wondering why I could not get myself out of the hospital earlier. I have slowly picked up tips in my weeks there, and today, I won the game!
"Winning the game" in the medical training sense means discharging all your patients the day before a routine day (a day when you are not admitting patients to the hospital). It's a big deal because it means that you don't have to go into the hospital on your routine day--an extra day off! I didn't even realize I had won the game until my last patient left the hospital and my list said "no patients found". There were lots of high fives all around, but it felt that the stars aligned for this to happen. I don't know about other programs, but I see it as pretty unlikely that I'll repeat this feat again.
Being in a different hospital means many things are different. As an intern, it's my job to get stuff done--tests, labs, consults, etc. If they don't get done, I see it as me failing at my job. Patients staying extra days in the hospital means higher risk for hospital-acquired infections and complications, so all around it's frustrating for me and somewhat dangerous for my patient when there are delays in diagnosis and therapy.
The VA computer system is regarded as one of the best if not the best in the country. However, if you don't know how to fully utilize it, it can be a complete disaster! Although I did a rotation at this hospital as a medical student, I wasn't familiar with all the steps it takes to get things done. It was taking me 30 minutes to figure out how to order regular finger sticks to test blood sugar levels on a diabetic! There's also cultural things about each hospital--which antibiotics they tend to use, availability of certain imaging, consults, and pharmacy rules. If you don't know these things, you'll definitely be less efficient.
However, I'm on another great team, and we all helped each other out as best we could. My first week was plagued with late nights cursing the separate menus on the computer system, and I would come home every night wondering why I could not get myself out of the hospital earlier. I have slowly picked up tips in my weeks there, and today, I won the game!
"Winning the game" in the medical training sense means discharging all your patients the day before a routine day (a day when you are not admitting patients to the hospital). It's a big deal because it means that you don't have to go into the hospital on your routine day--an extra day off! I didn't even realize I had won the game until my last patient left the hospital and my list said "no patients found". There were lots of high fives all around, but it felt that the stars aligned for this to happen. I don't know about other programs, but I see it as pretty unlikely that I'll repeat this feat again.
Saturday, September 15, 2007
Performing my IADLs
When I started internship, I knew that posting would be intermittent, but the longer it had been since I posted, the more pressure I felt to write something especially insightful. The days turned into weeks, and here we are at a whole month since my last post! I've read about this happening to other physicians-in-training with blogs, and I decided just to post about whatever comes into my head. Here we go!
The last month was fantastic! I was on an outpatient rotation, which entailed seminars and clinical experiences aimed at residents interested in primary care. While I should probably write about my excellent clinical and didactic experiences, the best part of the last month was having time for what physicians call "Instrumental Activities of Daily Living" or "IADLs". During a geriatrics conference, IADLs were jokingly referred to as "Things interns don't have time to do." It's funny but sadly true. IADLs include the following:
IADLs contrast with another scale used by physicians describing Activities of Daily Living (ADLs). They are things that interns (hopefully) still do regardless how busy they are, including bathing, brushing teeth, feeding themselves, dressing, and using the toilet. However, I've been known to be driving home at 9 pm realizing I hadn't been to the bathroom since the morning, and there are days when I would have starved had it not been for the granola bars in my pockets.
I really do want to write about some of my other experiences during this month, including giving a talk in front of my fellow interns and residents and learning about outpatient pain management. However, I'm basking in my last two consecutive days off until January.
The last month was fantastic! I was on an outpatient rotation, which entailed seminars and clinical experiences aimed at residents interested in primary care. While I should probably write about my excellent clinical and didactic experiences, the best part of the last month was having time for what physicians call "Instrumental Activities of Daily Living" or "IADLs". During a geriatrics conference, IADLs were jokingly referred to as "Things interns don't have time to do." It's funny but sadly true. IADLs include the following:
- Using a telephone. During my last wards month, I had many voice mails from my mother, and at one point, she called my husband to make sure nothing had happened to me. Well, internship happened to me, but during the last month, my whole family came to town to visit. Plus, I was able to chat with some old friends I hadn't spoken to in a few months.
- Grocery shopping and cooking meals. After burning myself on the oven my first month, I've not been as keen to cook. I do have a few recipes that I can throw together in a few minutes, such as fried rice or spaghetti, but after two years of marriage, my husband is now learning how to cook basically out of necessity. Plus, my stomach wasn't adjusting well to our greasy take-out diet. Over the last few weeks, I was able to indulge in one of my favorite hobbies--trying new recipes. Yesterday, I made my own pizza dough, and I put some in the freezer for the upcoming wards month along with some frozen vegetables.
- Housekeeping. During this month, my husband and I actually bought some furniture and finished unpacking our boxes from our move over three months ago. Yay!
- Laundry. If my husband didn't wash my clothes for me, I probably would be wearing scrubs daily because the hospital launders them. I hate wearing scrubs mostly because they don't fit and drag on the ground behind me, making me look like a kid playing doctor, but if my husband goes on strike, I'd wear them.
- Paying bills. Credit cards would never get paid without the automatic payment feature.
IADLs contrast with another scale used by physicians describing Activities of Daily Living (ADLs). They are things that interns (hopefully) still do regardless how busy they are, including bathing, brushing teeth, feeding themselves, dressing, and using the toilet. However, I've been known to be driving home at 9 pm realizing I hadn't been to the bathroom since the morning, and there are days when I would have starved had it not been for the granola bars in my pockets.
I really do want to write about some of my other experiences during this month, including giving a talk in front of my fellow interns and residents and learning about outpatient pain management. However, I'm basking in my last two consecutive days off until January.
Wednesday, August 15, 2007
My pager: Putting things in perspective
I meant to write this post last week, but I kept putting it off. Anyway, I had that really crazy week, and as my husband pointed out, it wasn't a bad week, just a very busy one. I went to the beach on my day off, and while soaking in the sun, I was able to reflect on my week.
With a little distance, I could see that I was getting overwhelmed. What I really needed to do was take a few deep breaths and tick things off my to do list one at a time. It's easy to feel overwhelmed when my pager is going off every 30 seconds interrupting my routine. Coming from the ICU, I was used to returning pages right away, but I've learned that I don't always need to sprint to the nearest phone when my pager goes off on the wards. Sometimes I should take a few minutes and finish eating or the conversation I'm having with a consultant. About 99% of the pages I receive are not urgent at all. Most of the time it's the phone number of a nurse who wants to tell me that someone didn't eat any breakfast or would prefer ibuprofen over tylenol. With anything urgent, they text message me what I need to know immediately. After figuring that out, I've managed to avoid heartburn from gobbling up my lunch in the elevator and actually sit through a few conferences.
I'm on my last week of this wards block. Tonight will be my last overnight call for a few months because I'll be on a few specialty services (cardiology, oncology) that have different call schemes. While I like admitting all my own patients, I won't miss overnight call and how it screws up my sleeping schedule for days. I can't wait for next week because I start a whole month of primary care!
With a little distance, I could see that I was getting overwhelmed. What I really needed to do was take a few deep breaths and tick things off my to do list one at a time. It's easy to feel overwhelmed when my pager is going off every 30 seconds interrupting my routine. Coming from the ICU, I was used to returning pages right away, but I've learned that I don't always need to sprint to the nearest phone when my pager goes off on the wards. Sometimes I should take a few minutes and finish eating or the conversation I'm having with a consultant. About 99% of the pages I receive are not urgent at all. Most of the time it's the phone number of a nurse who wants to tell me that someone didn't eat any breakfast or would prefer ibuprofen over tylenol. With anything urgent, they text message me what I need to know immediately. After figuring that out, I've managed to avoid heartburn from gobbling up my lunch in the elevator and actually sit through a few conferences.
I'm on my last week of this wards block. Tonight will be my last overnight call for a few months because I'll be on a few specialty services (cardiology, oncology) that have different call schemes. While I like admitting all my own patients, I won't miss overnight call and how it screws up my sleeping schedule for days. I can't wait for next week because I start a whole month of primary care!
Sunday, August 5, 2007
What a week!
If I've been painting a rosy picture of internship, maybe it's because I've been lucky enough to have a few good weeks or maybe a bad day here or there mixed with mostly good days. This week was terrible. Everyday was a nightmare. When I tried to explain my bad days to my husband, he pointed out that nothing really bad (e.g. patient dying, giving someone the wrong drug) happened; I just had long, busy days. The wards are a crazy balancing act, and I'm working on my juggling skills. Our schedules aren't so bad if everything goes according to plan, but some things can really screw up your day:
1. When admitting, all your new patients can come to the floor at the same time. The way we're assigned patients is designed to avoid this. However, patients come from the ER, directly from clinic, transferred from other hospitals, and transferred from the ICU. Although I hear about the patients at neatly spaced intervals, through the mysteries of patient transport, sometimes they all come at once. So, I have to run around and make sure they're all stable and then try and do a quick assessment to put some basic orders in the computer (patients will complain if they don't get dinner, and nurses will complain if there are no orders in the system!). Once they're stable with dinner on the way, I have to figure out what's wrong with my new patients and how I'm going to fix them (or at least what to order to help narrow down the differential).
2. Patients can become unstable. Nothing can destabilize my day like a call that says, "Your patient is having shortness of breath and is desating to the 80s." Yikes! People not being able to deliver oxygen to their organs is really bad, and it requires dropping whatever you were doing (e.g. rounding with the team, writing prescriptions so another patient could catch his 2 pm ambulance to rehab, eating lunch and enjoying a teaching conference, or preparing your signout to leave for the day) and running in that direction. Having been in the MICU, I have some experience with unstable patients, but I also have more patients to take care of. Once the patient's oxygen saturation has gone back up with a face mask, blood has been sent to the lab, the STAT portable chest xray team are on their way, when is it okay for me to resume my other activities? For me, not for a while. The best I can do is park myself at a portable computer outside the patient's room and try to move my other patients along, but it's hard to think about anything else except my patient possibly needing to be moved to the ICU.
3. The absence of a member of your team. I'm fortunate to be on another great team, but when one team member is gone, things can get crazy. Sometimes they're at clinic or have the day off, and in addition to my work, I'm responsible for their patients, too. Double the patients to take care of! Whenever that's going to happen, we try to make sure everyone is "tucked" (e.g. discharge summaries and prescriptions ready for possible discharges, labs ordered, consults called, etc.) but sometimes you can't predict what will happen when you're covering someone else's patients. Also, having a covering attending or resident can throw everything up in the air as he or she can have a different interpretation of events and labs and want to completely change the plan. Of course, they'll say to me, "It's your patient, and your team has a plan. However, I'm not sure why you haven't considered this possibility." Well, when you put it like that, I'd be hard pressed not to go along with their suggestions.
4. Medical students. I absolutely love having medical students and teaching them, but in the crazy juggling act that is my day, finding time for them can be difficult. As I was a student just a few months ago, I remember very well what it was like to be a med student on the wards. I try to get my students out as early as I can although sometimes they insist on staying for some unknown reason. I'll take a few minutes here or there to teach them something (e.g. reading chest xrays or EKG's, going over the differential or workup of a particular problem), but some days the best I can do is try to be a role model of a busy but hopefully intelligent and efficient intern.
What makes these crazy days better? Help from my resident and moral support from my co-interns during the day, and when I come home, a big hug and some understanding from my husband that it'll take me a few minutes to shake off my grouchy mood.
Time to go to the beach, so I can start another week rejuvenated.
1. When admitting, all your new patients can come to the floor at the same time. The way we're assigned patients is designed to avoid this. However, patients come from the ER, directly from clinic, transferred from other hospitals, and transferred from the ICU. Although I hear about the patients at neatly spaced intervals, through the mysteries of patient transport, sometimes they all come at once. So, I have to run around and make sure they're all stable and then try and do a quick assessment to put some basic orders in the computer (patients will complain if they don't get dinner, and nurses will complain if there are no orders in the system!). Once they're stable with dinner on the way, I have to figure out what's wrong with my new patients and how I'm going to fix them (or at least what to order to help narrow down the differential).
2. Patients can become unstable. Nothing can destabilize my day like a call that says, "Your patient is having shortness of breath and is desating to the 80s." Yikes! People not being able to deliver oxygen to their organs is really bad, and it requires dropping whatever you were doing (e.g. rounding with the team, writing prescriptions so another patient could catch his 2 pm ambulance to rehab, eating lunch and enjoying a teaching conference, or preparing your signout to leave for the day) and running in that direction. Having been in the MICU, I have some experience with unstable patients, but I also have more patients to take care of. Once the patient's oxygen saturation has gone back up with a face mask, blood has been sent to the lab, the STAT portable chest xray team are on their way, when is it okay for me to resume my other activities? For me, not for a while. The best I can do is park myself at a portable computer outside the patient's room and try to move my other patients along, but it's hard to think about anything else except my patient possibly needing to be moved to the ICU.
3. The absence of a member of your team. I'm fortunate to be on another great team, but when one team member is gone, things can get crazy. Sometimes they're at clinic or have the day off, and in addition to my work, I'm responsible for their patients, too. Double the patients to take care of! Whenever that's going to happen, we try to make sure everyone is "tucked" (e.g. discharge summaries and prescriptions ready for possible discharges, labs ordered, consults called, etc.) but sometimes you can't predict what will happen when you're covering someone else's patients. Also, having a covering attending or resident can throw everything up in the air as he or she can have a different interpretation of events and labs and want to completely change the plan. Of course, they'll say to me, "It's your patient, and your team has a plan. However, I'm not sure why you haven't considered this possibility." Well, when you put it like that, I'd be hard pressed not to go along with their suggestions.
4. Medical students. I absolutely love having medical students and teaching them, but in the crazy juggling act that is my day, finding time for them can be difficult. As I was a student just a few months ago, I remember very well what it was like to be a med student on the wards. I try to get my students out as early as I can although sometimes they insist on staying for some unknown reason. I'll take a few minutes here or there to teach them something (e.g. reading chest xrays or EKG's, going over the differential or workup of a particular problem), but some days the best I can do is try to be a role model of a busy but hopefully intelligent and efficient intern.
What makes these crazy days better? Help from my resident and moral support from my co-interns during the day, and when I come home, a big hug and some understanding from my husband that it'll take me a few minutes to shake off my grouchy mood.
Time to go to the beach, so I can start another week rejuvenated.
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