This Simple Philosophy Will Help You Become a Better Intern

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Starting intern year of residency is a leap of faith. One second you’re a med student, and then all of a sudden, you’re calling (some of) the shots with your new-fashioned MD/DO moniker.

While it’s empowering to finally put your skills and knowledge to the test, it’s intimidating to try and sort out what you can handle on your own, and what necessitates “bothering” your senior residents.

My (Not so) Excellent Intern Adventure

My intern year jitters weren’t helped by the fact I was starting on a surgery rotation. I knew that meant there’d be long days in the OR, running around the floor, placing orders, writing discharge summaries, and trying to put out all the small fires that would crop up.

And, to make matters worse, I was starting day one—my very first day of intern year—on night float! That meant I wouldn’t be surrounded by my comforting co-interns with whom I could commiserate. I’d be in a musty call room, not sleeping, tossing and turning while returning pages from the not one, not two, but three pagers weighing down my scrub pants.

Memories of My First Shift

I’ll never forget that first night. I took sign out from the daytime interns, and when the last one was ready to head home, I asked him, “So, what do I do?”

“I don’t really know,” was his reply.

(Not exactly what you want to hear.)

The Key Lesson I Learned That First Week

To say things were tough those first few days would be an understatement. But one lesson came from that harrowing first week. It’s something that’s proven true throughout my career, and continues to bear repeating, even to this day.

And that’s the following:

Just go and see the patient.

Believe it or not, just doing that will clarify a LOT of things for you.

Here are just a few examples from my whirlwind first week that’ll illustrate the usefulness of this simple rule.

Case #1: A Fresh-Faced Intern

I was sleeping when I got a call from the floor nurse around 1 a.m.

“Mr. Oliver in 352 is having a lot of abdominal pain,” they said. “He already went through his dilaudid PRNs. Can he get more?”

Of course he could get more. Mr. Oliver had a brand new ostomy, and he was hurting. On POD#1, he was certainly entitled to IV analgesia to help get him through the night.

But I was curious. Why did he need more Dilaudid all of a sudden?

The allure of the call room bed, in its glorious silence and darkness, was a strong force to overcome. But the voice of my senior resident echoed in my head. He mandated that if I had any doubts, “Just go and see the patient.”

I shook out the cobwebs and tried to put my awake face on as I headed towards 352. And there’s Mr. Oliver, wincing in bed, on the verge of tears. I ask him how he’s feeling (as if it wasn’t already clear), and he can barely respond between the holding back of tears.

“Hurts. Hurts a lot,” he said.

I removed his blankets to get a look at his ostomy site. My surgical experience as a medical student was split between a month of vascular surgery and a month of trauma surgery. I knew what a healthy AV fistula looked like, I could do Doppler pulses in the feet, and could hold my own in a trauma secondary survey.

But what was an ostomy supposed to look like?

Upon seeing the site, the question no longer mattered. Even a lay person would know that something was wrong here. What should have been a speck of pink bowel at the skin surface looked like three links of dark sausage sitting on top of the belly.

The bowel had herniated through the ostomy site, and its blood supply was compromised. The bowel was getting ischemic, hence the patient’s extreme pain. I told the nurse to give him the Dilaudid, and gave my senior a call.

My senior resident came by, and within minutes, the attending surgeon was on the way to the hospital for an emergency takeback surgery.

Had I just thrown more Dilaudid at the pain, under the guise of “surgery is gonna hurt,” the bowel might have grown more ischemic, and really set the patient up for further harm and decompensation.

Here I was, in week one, and already I had seen the value of going and seeing the patient.

Case #2: Thanksgiving Morning

So this was also intern year, ergo, I was working on Thanksgiving. Mr. Jones, a 40-something man with prostate cancer, was in the ICU on POD#1 after a technically difficult radical prostatectomy.

I got a call because Mr. Jones is having belly pain. (Notice a common theme here?) Odd, I thought—he’d looked good enough for discharge at the beginning of the shift.

Having seen earlier this year what being in the throes of “belly pain” can be a harbinger of, I headed over to the unit to see what was going on.

The patient’s abdomen was rock hard and full of ecchymoses. His previously flushed, sun-kissed face was growing paler.

As I was examining the patient, I fielded a phone call from the lab.

“Critical values to report on the patient in bed 13.”

“Go for it,” I responded.

“pH 7.01, lactate 14, bicarb 11, hemoglobin 6.2.”

The patient was exsanguinating into his abdomen. I called for help, we upgraded our IV access, ordered blood, called anesthesia for an intubation, and made preparations to go to the OR.

I had suspended disbelief and went to see a patient in pain, only to discover his rapid decompensation. It had been a situation where every minute mattered.

He was eventually stabilized, the bleeder was found and oversewn, and he was discharged later that week.

Case #3: The Hot Potato

In the busy world of anesthesia, it’s not uncommon for attendings to be tied up with an induction or an airway, and to have a colleague pre-op a patient for us.

That was the case for me on a recent morning. I remember reading the patient’s chart: a 74- year-old woman scheduled for a “quick angiogram.” She had severe aortic stenosis, EF 10-15%, end-stage renal disease on dialysis, and COPD. Even on her best day, she’d be a tricky candidate for any procedure, big or small.

My colleague went through the consent with her, and let me know that, “She looks…not so hot. You should probably lay eyes on her before they roll back.” That was code for “I’m not sure you want to do this case at all.”

I went to see the patient. She was having trouble mentating and forming coherent sentences. Whenever she tried to move in bed, she lost her breath because of severe pain.

Clearly, something wasn’t right. We sent her to the ED instead of the OR. On a CT scan, they see she has a filling defect in her superior mesenteric artery. Less than an hour later, she codes and dies.

Had I not seen the patient myself, and said, “It’s just a quick sedation case, no big deal,” she likely would have died on the table. And as soon as we connected her IV and gave her a single medication, it would have been “the anesthesia” that killed her. The patient was going to leave the earth that day at 1:13 p.m., with or without a surgical procedure.

The point of the story is that sometimes the “hot potato” falls in your lap. But laying eyes on the patient and using the gestalt judgement we’ve compiled over the years led us to take surgery off the table entirely.

Final Thoughts

Something I’ve learned is that the powerful lessons always hold true, and are not oft forgotten. Take it to heart—whenever in doubt, go and see the patient. You’ll be glad you did.

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And for more (free!) tips for residency, check out these other posts on the blog:

By Brian Radvansky, MD