Internship: Ready, Set, Go!

by Callie Thompson, M.D.


Congratulations to all of you newly minted Doctors of Medicine! It is almost time to start your internships! You are probably trying to imagine what it will be like, and you are probably excited, nervous, scared, and maybe even a little nauseous.

This transition from medical student to doctor will be a big adjustment. But don't worry, you really can (and will) do this. I will start with a few general tips for how to succeed in your internship and then finish with some more specific tips that you will hopefully find helpful.

1. The patient comes first. Always. They are your North Star. When you lose your way, ask yourself "What is best for my patient?" and do that.

2. Be the doctor. I know, this one seems obvious, but you just graduated 3 weeks ago and now someone is calling you "Dr. So-and-so" and you feel both scared and like a total fraud almost all of the time. However, your patients and your team still depend on you. You are their "Dr. So-and-so" and you need to act like it. Have assessments, have plans and be willing and able to explain your reasoning for them.

And don't forget to introduce yourself as "Dr. (YOUR LAST NAME HERE)"--you earned it.

3. Always worry, but never worry alone. If you load that proverbial boat early, at least you won't sink alone. If someone on the floor is going south, assess them and then let your senior resident know. Immediately. No one expects you to be perfect; you will be learning and improving for the rest of your life, but we do expect that you will not keep secrets from us.

4. Never lie. Not to your seniors, not to your attending, and not to the patient.  I know that these people will be looking at you and wanting to hear "good news" but your only job is to be honest, to tell them the truth. Trust is what your relationships with these people is built on; lying, even once, can permanently damage that relationship and worst of all, put the patient at risk.

5. Utilize the nurses, but don't let them use you. The nurses can and will be your best friends. They have experience, and they can teach you infinite amounts. If they call and tell you someone is sick, listen to them. Don't let your ego get in the way. Everyone is on the patient's team. The flip side of this is that some people will take advantage of your "newness" and they will ask you to do things that seem wrong to you. If that is the case, don't do it. Politely tell them that you need to check with your senior, and check with your senior.  No one should get offended by that, as long as you remain polite and respectful.

6. Ask your senior residents and attendings for their expectations of you. There is nothing worse than finding out that you are falling short of expectations that you didn't know existed. Asking for expectations up front will lessen their potential frustrations, and yours.

7. Ask for feedback from your seniors and attendings. Don't wait for the end of a rotation to get an evaluation. That leaves you no opportunity to fix things and get better. Ask for feedback in the middle of your rotation (a great time for this is when you are finishing up a case) and then they will know that you were interested in improvement, and they will be able to recognize when you have improved.

And for the interns who are parents:

8. Set goals for yourself and your family. Make promises to yourself and your family about when you will study and prepare for your patients and when you will just be present for them. This is going to be an especially big period of adjustment for you, your partner, and your child(ren), but you'll get through it. Have patience with yourself and with them.

Now for a few specifics...

Must-use Websites & Apps:

1. NCCN Guidelines. The absolute best resource for guidelines for treatment of cancers. This site will help you immensely in clinic--and they have an app.

2. Up-to-date. Obviously.

3. Epocrates. Again, obviously.

4. ACGME case log mobile app. Immediately enter all of your cases after you complete them. Seriously, don't let them stack up. I had to enter an entire year's worth at one point, and it was obnoxious. Open the ACGME case log site on your iPhone (if you know how to do this on a non-Apple product please weigh-in in the comments below), click the rectangle with an arrow icon on the bottom of the page, and then click "add to home screen."

5. Twitter. Join twitter, follow people and organizations that you are interested in, and just watch. I have read more journal articles in the two months since joining twitter than I have in the prior two years. I recommend the Association of Women Surgeons, American College of Surgeons, Journal of Trauma, Annals of Surgery, NEJM, JAMA, and Journal of Burn Care and Research, but there are many more.

6. DrawMD apps. A perfect way to explain an operation to a patient.

7. Other useful (but potentially costly) resources include the SCORE curriculum (this will be an institutional license, so your program may not have it), the Gray's anatomy app, and SESAP 14.

8. Useful books (I like e-books because they are easier to carry around): Greenfield's Surgery, Zollinger's Atlas of Surgical Operations, and Operative Dictations in General and Vascular Surgery.

Organizing Your Day:

Pre-rounding, rounding, clinic, OR, afternoon rounding, sign-out. The schedule probably hasn't changed too much from medical school, except that you will be the one in charge of getting things done while still being in clinic and in the OR. Multi-tasking and triaging will be vitally important, but they can't really be taught. They are best observed and then applied in a trial and error manner until you find a method that works for you. I will give you this tip: discharge your patients before doing anything else (unless the something else is urgent). With computerized order entry, a lot of the discharge orders can be done the night before. This is also true for the discharge summary.
The big question is, what should you do when you get home from work? You should NOT start working again immediately. You should NOT study or read for the next day's cases. You SHOULD sit down and relax. Take a few moments for yourself. Eat some dinner. Maybe have a glass of wine. If you have a significant other or kids, spend time with them--see above. If you don't, make some plans with friends (co-residents make great friends) or give your family a call. Then, set a time (maybe 1-2 hours after you get home) to study, prepare for the next day, and/or check in on your patients.

What You Should Know for Every Case/Procedure You Do:

Prior to scrubbing in to a case or performing a procedure you need to know...

1. Your patient's history (including being familiar with their imaging)

2. The indications for the operation

3. The steps of the operation (including the anatomy)

4. The pitfalls for those steps

5. The general perioperative management

You may not be asked anything during the case but you should know these things all the same.
If you have a question or can't see during the case, ask politely if it would be a good time to ask a question or for you to take a closer look. Be okay if the answer is no because the patient comes first.
At the end of every case, talk with the senior resident and attending about the perioperative plan for the patient. You should know the plan for every drain/line, diet, pain management, and wound care. You should also know the criteria for discharge. (Hint: if you do this, you will almost always have an acceptable plan for the patient on morning rounds.)

Best of luck to all of you and congratulations, again!

For those of you who have already completed internship or at the tail-end of your intern year, do you have any additional tips or advice? What helped you out most during your first year as a new surgeon-in-training? Let us know in the comments below!

~~~

Callie is a resident in general surgery at the University of Washington. She will be entering her fourth clinical year at the end of June 2013 after completing a two year research fellowship. Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children under the age of 7.
 

Green Solutions for the OR - 2013 Contest

The Association of Women Surgeons, in partnership with Practice Greenhealth, Invites Entries for the

2013 Competition: Green Solutions for the Operating Room

                    

This contest is designed to facilitate discourse between students, residents and perioperative faculty and staff about ideas that demonstrate environmental responsibility in the operating room through reduction of energy use, preservation of natural resources and/or effective waste management. DEADLINE IS AUGUST 4^th, 2013.

Contest Description:  To enroll in this contest, please submit an innovative solution that has been or can be implemented in the operating room to protect, restore, and/or preserve the environment. Your idea can incorporate one or more of the following: energy efficiency, pollution prevention, preservation of natural resources and/or waste management. This idea can be in the form of a proposal (has not yet been implemented) or a summary of a project that has already been initiated. Entries will be judged on originality, feasibility and potential impact.


Prizes: Recognition, two $200 monetary prizes and a complimentary registration to the 2013 AWS Conference will be awarded to the top two submissions.  The first place submission will also receive free admission to the Greening the OR® workshop at the 2014 Practice Greenhealth CleanMed Conference (www.cleanmed.org). Winning submissions will also be posted on the AWS Website if the submission is free of copyright restrictions.

Inspiration: Check out Practice Greenhealth’s Greening the OR® Initiative website to jumpstart your ideas (https://practicegreenhealth.org/initiatives/greening-operating-room)

Who can participate: The contest is open to all students, residents, physicians, nurses, and allied health professionals involved in the care of patients in the perioperative setting.

How to Enter:  Gather your best ideas, prepare a document, and submit!

Please include the following sections in your submission:

·             Title and Author(s) (including affiliations)

·             Description of targeted problem

·             Proposed solution: include information about general budget, personnel required, need for training if applicable, etc.)

·             Anticipated outcome and method for measuring the outcome

·             Figures and photos optional

·             Please specify if the submission is free of copyright restrictions.

Submission Guidelines:

·             Limit the entire submission to 500 words or less (excluding the title and authors).

·             The file name should be your last name followed by your first name (i.e. “SmithJohn”).

·             Save the file as a WORD document

·             Send the document as an attachment by e-mail to the AWS Greener OR Contest address -AWSgreenerORcontest@gmail.com.  Receipt of your submission will be confirmed by email. 

·             Submissions must be received no later than 5:00 PM EST Sunday, August 4, 2013.

Notification: Contest winners will be notified by September 1, 2013. All entries will be compiled and shared during the 2013 Association of Women’s Surgeons Annual Fall Conference in Washington DC on Sunday, October 6, 2013 (held prior to the American College of Surgeons Clinical Congress).

 Questions?  Please do not hesitate to contact us at AWSgreenerORcontest@gmail.com.

Disparities

by Marie Crandall, MD, MPH, FACS

Poverty

Living in Detroit as a child, I learned that if your water got turned off, you just went down to the city Water Board, paid $10, and got your water turned back on. When I started high school in the early 1980s, our family moved to Northern Michigan. It was there I met folks who didn’t have running water. I have countless memories of stumbling out past snow-covered woodpiles to drafty outhouses, then pumping ice cold water over my hands before returning to not terribly public health-focused high school parties. Seeing both urban and rural poverty and the ensuing late-diagnoses of cancer, alcohol-induced car crashes, and gunshot wounds that ruined lives absolutely influenced the course of my life and my career.

The crushing effects of poverty are pervasive and have a tremendous impact on health disparities, as income and race have been found to predict outcomes in nearly every kind of illness, from trauma to appendicitis to cancer, though we are only just beginning to understand the mechanisms. However, programs that improve housing stability and access to healthcare and healthy food choices have been shown to improve ALL health outcomes for children, underscoring the principles of the social determinants of health. If we can address some of the nutrition, education, and health issues of children living in poverty, we may be able to narrow the gap of subsequent health outcomes disparities. Likewise, if issues of homelessness and substance abuse could be more comprehensively addressed, there is evidence to suggest that Emergency Room visits and healthcare expenditures can be reduced.

Trauma

Injury is the leading cause of death of all Americans ages one through 45. Gunshot wounds take the lives of 30,000 Americans every year. There is an epidemic of violence and endemic acceptability of violence in our communities with African American and Latino youth suffering a disproportionate amount of gun violence in the United States. Simply providing excellent trauma care is not enough. Programs like CeaseFire/CureViolence in Chicago and Safe Streets in Baltimore are necessary adjuncts to address the underlying root causes of handgun violence. Ensuring safe access to schools, improving educational and earning potential for underprivileged youth, and teaching conflict resolution skills as alternatives to violence are essential to preventing the loss of life that takes such a heavy toll on our disadvantaged communities.

Fear of flying is one of the most common phobias in America, affecting nearly 40 million people. Yet if you ask any group of people if they know someone who has been killed in a commercial aviation crash, almost no one will raise their hand. However, most people have no fear at all of getting behind the wheel of a car, even when intoxicated, though nearly 30% of Americans have lost someone in a motor vehicle crash. However, there are things you can do to make your ride safer, like wearing a seatbelt, which reduces the risk of death for a similar velocity crash by up to 80%. Many researchers have found that people of color are less likely to use a seatbelt; this disparity is completely eliminated in states with primary seatbelt laws. These data suggest that primary prevention can be effective in some cases to decrease racial disparities in health outcomes.

Upshot

So, what does all this mean? I believe that by recognizing the disparities around you, affecting your families, friends, and communities, and by striving consistently to acknowledge and eliminate them, you will be a better clinician and global citizen. Your role may include public health work, competent clinical care, health policy, and/or advocacy. But a holistic worldview, with an understanding of the social determinants of health that affect all of us, is essential to the comprehensive care of your patients.

What health disparities have you witnessed in your community or during your travels? What efforts have you made (or wish to make) to transform the world into a better, healthier place? Leave your comments below!

~~~

Marie Crandall, MD, MPH, FACS is an Associate Professor of Surgery and Preventive Medicine in the Division of Trauma and Critical Care at Northwestern University Feinberg School of Medicine. She is originally from Detroit, MI, a product of Head Start and local public schools. Dr. Crandall obtained a Bachelor’s Degree in Neurobiology from U.C. Berkeley in 1991, and completed her M.D. in 1996 at the Charles R. Drew/U.C.L.A program in Los Angeles. She finished her General Surgery residency at Rush University & Cook County Hospital in 2001, and in 2003, completed a Trauma & Surgical Critical Care Fellowship at Harborview Medical Center in Seattle, WA. During her fellowship, she obtained a Masters in Public Health from the University of Washington. Dr. Crandall performs emergency general and trauma surgery, staffs the SICU, and is an active health services researcher. Dr. Crandall loves travel, triathlons, hiking, and is a passionate animal rights activist; you can follow her on Twitter @vegansurgeon.