A Letter to the New Interns Who Have Replaced Me

Well, intern year ended. Second year began. For me the transition has been gentle. I have spent the first month of second year on a primary care rotation, where there isn’t much difference between the role of an intern and the role of a resident. Though I will probably not go into the field, I love primary care. The triumphs are not always dramatic (aka restarting a heart) but they are profound: helping the family of a boy with behavior problems identify the anxiety disorder that is causing his outbursts, seeing the patients I met as 4 day olds last summer toddle in on two legs for their year-old check-ups (really there is nothing like it), hearing from one of my patient’s mothers that her husband quit smoking as a result of the discussion we had at our previous visit. In primary care, you never know which of the thousands of stones you throw (Put the baby to sleep on her back! Include a book in your bedtime routine! Brush your teeth! Wear a condom!) will cause a ripple of positive change in the life of a child, so you just keep meeting your patients with an open mind, ready to throw as many stones as you can in the time allotted (20 minutes or 40 minutes which always turn into 60 minutes).

Meanwhile, in what feels like a parallel dimension, my fellow second years have started the rotations that will define this year: NICU, PICU, onco, cardiology. They are caring for sicker patients and doing so without direct supervision from senior residents. It reminds me of the line from the Sound of Music (showing every night at our house from 6:30-6:45pm, bring your lederhosen!): When the Lord closes a door, somewhere He opens a window. Except in medical training it is kind of the opposite: When the Lord opens a door, somewhere He closes a window. That is to say, as soon as you are comfortable, you are pushed back out of your safety zone. On the one hand, the absence of direct supervision is scary, on the other hand it is the only way to learn while the safety net of fellows and attendings is still there to catch you.

Over the course of the month, I have gotten to meet some of the new interns as they arrive for their first and second primary care clinic sessions. They are eager, tentative, and still appear moderately well-rested. Though I am sure it isn’t written on my face, I feel a world of emotion for them: fiercely protective, sad that they have to go through the hard moments of internship, excited for the greater mastery and confidence they will feel as a result of their experiences, worried that something in their spirits will be lost in exchange. On the first day of the vacation that ended my intern year (almost a month ago now – hard to believe!) I started a letter to them. There was so much I wanted to tell them about what to expect, how to cope, and how to thrive. Now that I’m about to start three months of 28-hour call every fourth night, I figure it’s time to send it, before the lessons of last year are replaced by the lessons of this year. So, this is for you, new interns, both here and everywhere. Thanks for showing up and taking over!

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Dear New Interns:

Welcome to residency! Much advice will be given to you in the coming months about how to do intern year. Everyone who has gone through the process of becoming a doctor has his or her own insights and advice. Some of these will resonate with you now, some may suddenly resonate at 2am on a hard night of call, and some may never resonate. Everyone experiences residency differently.  That said, I feel compelled to share with you some of the insights I have gained, in the hopes that they might help you navigate the year ahead.

Be graceful about what you know and what you don’t know. Over the next year, you will be asked approximately 700,000 questions you don’t know the answer to. These questions will come from attendings, fellows, senior residents, your fellow interns, nurses, case managers, people looking for directions around the hospital, and most frighteningly, your patients. The good news is that there is one right answer: “I don’t know, but I can find out.” It will be tempting to fudge, to change the subject, or to guess. If someone is signing out a patient to you and they use an acronym like LFSGA-Beta (totally made up), don’t assume that you should know this and feel embarrassed to ask. Ask! It is an opportunity to learn and also a patient safety issue. My first day in the well baby nursery, I had to ask what “AFOF” meant. Turns out it means “anterior fontanelle open and flat” which I have subsequently written upwards of five thousand times. I felt a little sheepish having not known something so simple, but I was free to focus on more important things and all my little babies got their fontanelles appropriately documented using as few letters as possible. The same goes for calling consults. If you don’t understand the rationale for a treatment plan or just plain don’t understand what the heck the person said, don’t be afraid to ask for clarification. On the flip side, when you have heard crackles on a lung exam or feel strongly about which elements of the history are most important or did four years of PhD research in a particular disease, don’t be afraid to stand your ground or teach your colleagues. To use a tired but true cliche, medicine is a team sport and you will serve your patients best by leaving ego aside and doing your best to learn and teach.

Accept help: Throughout the first six months of internship, I felt annoyed and defensive every time my senior resident asked if I needed help. I saw this as an indictment of my ability to complete my staggering to-do list. Every time my senior resident asked to “run the list,” I felt ashamed if there were tasks that I had not done, even if I had been working non-stop since the morning. About two months before the end of the year, I realized that offers of help are just that: offers of help. Our jobs are hard and there is often more to do than one person can do, though there are many days when one person has to do it all. So when someone asks if they can help, just delegate a few tasks and be grateful. (Exceptions include medical students and your fellow interns who have already signed out who are using “Can I help you with anything?” as code for “Can I leave now?” in which case the answer is: “Nope, I got it! Have a great night!”)

Make time to see your patients: Right now, you might be thinking – this is crazy advice! Of course I’m going to see my patients! But the truth is that you will spend much more time in front of a computer than in patients’ rooms this year. There may not be an intuitive moment in the day to re-visit your patients after rounds, especially if you are on a day-float, night-float system where there is pressure to sign out your colleagues. In the time you do spend with patients, you will feel pressured to focus on medical stuff. But unless you are a person who doesn’t like people, in which case rethink this whole endeavor, practicing medicine without meaningful interactions with your patients will lead straight to burnout. Here is what worked for me: On long call nights after signing out, I would spend 15-20 minutes visiting with one of my patients in a less goal-oriented way. Even though I was tired, and didn’t see my daughter on those days, they were my favorite doctor days.

Looking up stuff on uptodate is also reading: I spent most of intern year feeling guilty and nervous about how little “READING” (those are lofty quotes, not scare quotes) I was doing. But I was looking up a ton of stuff on uptodate and emedicine in the course of my days and nights taking care of patients. Surprise! This counts. If you learn something you didn’t know by reading, it counts as “READING.” If you remember it the next time you encounter it, it counts as “LEARNING.” If you don’t remember it, which will happen often because (listen up creators of medical training schedules everywhere) sleep deprivation impairs your ability to learn and remember things, just look it up again. It’s like double reading points!

Lean into your weaknesses: If you are afraid of procedures, volunteer to do them. If a patient on the floor scares you because they are complicated or have a challenging family, visit them first. If a disease process is unfamiliar, seek out patients with that disease even if it means an extra admission on a long night. Volunteer to lead mock codes. This is your golden opportunity to get comfortable while you have a safety net.

Learn to accept the fact that you will make mistakes. Everyone who you admire in medicine has made mistakes and everyone has made mistakes that harmed a patient. When this happens to you, try to forgive yourself while at the same time learning from your mistake. Learn to sleep well again. This takes a lot of maturity.

Embrace the 24-hour day: In normal-people world, breakfast happens in the morning, dinner in the evening, and fun things happen on the weekends. In the world of medicine all 24 hours are fair game and you need to learn how to squeeze the things you need into the crevices available. Spending twenty minutes getting food from the cafeteria with one of your fellow interns at 3:30am counts as friend-time (would calling it happy hour be too much of a stretch?). Stealing an hour post-call to have breakfast with your significant other counts as date-night. Walking to work one day instead of riding the bus counts as both exercise and an opportunity for reflection. Writing this, it sounds depressing, but I’ve actually found it to be kind of fun, to inhabit the whole space of time. I’ve also become more productive, because I am not waiting for someone else to tell me what activities to do when in my day.

Along those lines, do not underestimate the power of the small gesture. This year you will be so busy, so pulled in so many different directions, it will seem impossible to take care of the relationships that matter to you. There will not be much time for long coffee dates with friends or trips to visit family members in distant cities. You may even miss a wedding or a baby naming and it will not feel good. The good news is that there will always be five minutes here and there and you should learn to use them to sustain your relationships (and take care of yourself, but more on that next). Send flowers to your girlfriend or mother as you are walking to the subway. Write little emails to friends if you don’t have time to write long emails. Take your child to the zoo at 9am for an hour before your ED shift. Call your friend from college as you are walking to the cafeteria to grab dinner. Don’t wait for a better time, take the time you have and keep your social connections as alive as possible.

Find ways to take care of yourself: I’ve heard many people describe their strategies for staying healthy and sane during intern year. There are as many strategies as there are people. But I think the path of self care during internship is a combination of making peace with the fact that you will be tired and stressed a lot of the time, while finding ways to relieve that stress in the time you have. Lots of people will tell you to exercise and eat right and I’m sure that’s not the wrong answer. I personally didn’t exercise intentionally even once during the year and ate more dessert than I would ever admit, but I spent many wonderful hours being lazy with my daughter, and a few hours each month writing in coffee shops, which is what makes me feel happy and centered and renewed. Choose 1-2 things that keep you grounded and make time to do them when you start to feel distant from yourself or burned out.

Everyone is your teacher: You will work with dozens if not hundreds of different people this year. Some you will love, some will rub you the wrong way. But all of them have something to teach you. At the end of the year, looking around at my fellow interns and the graduating seniors, I can honestly say that I learned at least one valuable thing from every single person I worked with, whether explicitly or by watching them practice. So don’t let a personality conflict get in the way of learning from the people around you.

When it comes to bullshit, don’t be a sponge and don’t be a boomerang: When someone treats you poorly, it usually means they are insecure, tired, burned out, or being pushed beyond their limits. When you are having an interaction that makes you feel like shit, refocus the other person on the well-being of patients. In that moment, you have the opportunity to help that person rediscover his or her best self. Here are two lines that have worked well for me: “I’m worried about this patient for xx reason and I need your help” and “Please help educate me.” Then again, some interactions will just go poorly. When that happens, resist the temptation to take it personally (sponge) or to have your own anger outburst (boomerang) and just try to get what you need to take care of patients.

Help each other honor your personal commitments: I’m not sure this needs much explanation. If your co-intern is getting married or it’s their grandmother’s 99th birthday party or they are the best man in their brother’s wedding and you are free to switch shifts or stay long, do it. Then don’t be afraid to ask for the same.

I will end by saying that for me, intern year was hard. It was hard to be a beginner, hard not to know the answers all the time, hard to be so sleep deprived, hard to be apart from my family and friends for so many hours and weeks and months. It was also hard (but good) to learn to make decisions that affect patients, to deal with uncertainty and my own anxiety about making mistakes, to attempt procedures for the first time, to fail and learn from failure. But there are also the successes, the camaraderie with fellows residents, the growing sense of competence and confidence, and the incredible feeling of making a difference in the life of a patient. The best advice I can give is: Face it with courage, self awareness, and kindness. Good luck!

4 thoughts on “A Letter to the New Interns Who Have Replaced Me

  1. Ohhhh… I love this post! You have really captured some of the pearls of intern year here. I love the “lean in” advice too. I think it took me awhile to appreciate this as an intern, but it is a valuable lesson.

    I also like the little praise of primary care. Glad you are enjoying it and we love having you as one of our residents!

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