advice for interns


Get a PDA of some kind, and put Epocrates on it. This free downloadable PDR gives all the essential information: drug names (brand and generic), indications, dosing, adjustments for renal/hepatic failure, side effects, contraindications, interactions, and pharmacology. There are also some nifty medical calculating gadgets that come with it, which will calculate FeNa for you, calculate equivalencies between different narcotics or steroids, and other mysterious details.

This program is tremendously useful for those times when, as usual, the patient gives you some funny spelling of their medication, or only knows the brand name and it’s a very tiny brand, or can’t remember the dosage. You can look up variations on the names, and find out what the usual doses are (if something only comes in 10 and 20mg, it’s very unlikely that they’re taking 300mg of it).

It’s also good for cancer patients being admitted for other reasons. The chief or attending will invariably ask what chemo regiment they’re on, and if you’ve run all the strange-lookings names on their med list through Epocrates, you can look brilliant by saying that they’re on X tyrosine-kinase inhibitor and Y mitogen inhibitor (which is usually used in advanced renal cell carcinoma, but has a new indication for this tumor).

There are some other good PDA applications, like the Johns Hopkins Antibiotic Guide (you can search by type of infection and bacteria involved, not just the name of the antibiotic), but to my mind Epocrates is the only really essential one. It’s gotten so ubiquitous that people really expect the interns and med students to have it available to solve problems with.

Another piece of advice that you won’t get from many attendings: invest in some good shoes. It will make your life much more bearable.

There’s a reason Danskos are so popular. They really do feel much better than any other shoes I’ve tried. Back for the first several months, I had “nurses’ shoes,” which did absolutely no good. My feet used to be so bad, by the end of a 14-hr day, that it hurt more to sit down in the car to drive home, than to keep standing up. When I finally decided to pony up ~$100 for some Danskos in January, this improved dramatically.

As any surgeon will tell you, the problem with sitting down is that you fall asleep much faster sitting down than standing up. So when you’re going to be tired a lot, you have to be able to keep standing up.

Speaking of being tired, I have to share our chairman’s take on fatigue, in the context of the ACGME’s mandate to teach residents how to deal with (or avoid) fatigue (and bear in mind this is one of the nicest guys you could meet, completely not fitting the surgical stereotype): “If you’re tired, you’re tired. Deal with it. What’s this fatigue nonsense?” I think some people think the surgeons are the ones who were born with less need for sleep than other people. While that may be true of the neurosurgeons, whom I have literally calculated to sleep no more than 4 hours every night, I don’t think it’s the case with most of us. We just have something we consider more important than sleeping. (Ask my family: when I was on vacation recently, I spent more than half the day sleeping. But when I’m at the hospital, as long as I’m not sitting down in a dark room for conference or radiology sessions, I’m usually fine. I’m scared enough of failing to do something important that it keeps me alert.) So I think most of us agreed with the chairman: of course we’re tired. It’s a fact of life. We just don’t spend much time thinking about it.

Anyway, get some good shoes; as long as your feet aren’t killing you, it’s easier to keep moving.

Learn to tie knots really well.

Admittedly, I’m a slow learner, but I was a couple of months into the year before I really grasped the meaning of a square knot, and I’m still working on how to pick up the threads so that they naturally fall into a square when I tie them. Privately with bare hands, and under observation in the OR with bloody gloves on, are two different things.

The nature of surgery is that the senior person is guiding what happens, and the junior is left doing a lot of the mechanical work: tying off vessels that the other surgeon has clamped, for instance. And believe me, they notice what you’re doing, especially the first few times you work with that attending. They notice how easily you tie, and how smoothly the knot falls, even if they don’t say anything.

One of the attendings interrogated me once: “Alice: can you tie knots well?” “Umm, I hope so, maybe.” “No. If you can’t tie, you’re no good to me. Can you tie knots well?” “Oh yes sir, absolutely.” “Okay, fine.” Later he told me, “If you can tie well, attendings will be willing to give you more to do. And if you can’t tie, they won’t trust you enough to let you do anything.” I’m pretty sure he noticed, because a few days later was one of my best days this year, during a liver transplant. I showed up just to watch, figuring that between multiple attendings and senior residents there would be no place for me, but they needed another pair of hands, and had noticed me hanging around their service whenever there was the slightest thing going on, and told me to scrub in. (I don’t think I want to do a transplant fellowship, but I’m fascinated by the surgery: the potential, the dramatic implications of taking organs from a dead person and using them to make another person stay alive, and the technical demands of the procedures.) So I got to help with the back-table dissection, and spent an hour tying dozens of tiny knots all over the specimen. That was one day, maybe because I knew it was vitally important, where my knots worked well.

If you’re in to surgery, you know how to get the clean left over sutures from the scrub techs at the end of a case (preferably the ones where you don’t conclude with blood and guts sprayed all over every inch of the instrument tables) and practice all over your scrubs and coats and pens and drawer handles. (The nurses like you better if you clean these off when you’re done.) I think it would be a great idea, though I haven’t managed it yet, to get some gloves to practice in.

Always be prepared.

Practically, this means you should at all times have the following basic supplies about your person:

- Trauma shears, because trauma patients are not the only things that need to be cut. Vascular dressings can be taken down with these; and I have found them handy for cutting JP stitches when it’s impossible to get ahold of a proper kit (after first cleaning them asepticly, of course). Attendings and chiefs tend to get testy when no one, not even the intern, can produce scissors upon demand. We live to cut, after all. Keep something semi-sharp handy.

- Lube. You’re a surgery intern, and there’s something else that you should be doing with practically every patient you see, especially the ones with abdominal complaints. (Which is one thing I love about general surgery: no matter what the reason for the consult, you can always write down the chief complaint as being abdominal pain, and you’ll be close enough.) You don’t make yourself popular with the seniors by saying, “I skipped the rectal exam because I thought you would like to see for yourself.” They are very happy to take your word for whatever you find.

- Notes on your patients. You should be able to spit out the creatinine, potassium, hemoglobin, and white count of all of your patients upon demand; and since I doubt that you can memorize all these, especially the first month, I recommend making a habit of writing down every lab value you see, since someone will inevitably ask about the one you didn’t write down. If the value is significant (new anemia, leukocytosis, renal failure) also make notes of the previous values so you can show the trend. At the beginning of the year, I also had to write down lists of medications, since I found it difficult to remember which antibiotics and antihypertensives everyone was on. As you get more used to the job, these things will start to stick without notes.

- A working pen. This is almost more important than any of these other things. If you can’t write on the chart, you basically can’t get any work done. The worst possible way to start the day (other than with a code) is with your pen running dry at the first chart, and there are no loose pens in the nurses’ station because either they’ve confiscated all of them and aren’t sharing, or they’re all using pencils tonight. With as many drug reps as there are floating around, this shouldn’t be too hard (but be wary of the cheap reps, whose pens fall apart after five days).

- A penlight is handy, if you can find a small one that works reliably. I tried four or five, but they all either quit working or fell apart on short notice, so now I borrow other people’s when I really want a cranial nerve exam. This is not efficient.

- Your beeper. I’ve tried leaving mine at home, and somehow it never makes the day any smoother. ;)

Other articles which are not as universally necessary: needles, scalpels, lidocaine, stitches. In my hospital, at least, these things are now (for “patient safety”) kept tightly locked up on only one floor, and it’s usually a long run through the hospital if you want to restitch a wound, or put a stitch on a bleeding vessel at the bedside, or anything like that. Fortunately, these happen rarely enough that you don’t get good return for the weight by keeping them in your pocket.

Here’s something important, which not many attendings will include in their list of valuable advice: Enjoy the last two free months of your life. Get out in the sun, get some exercise, spend time with family and friends – because that’s the last you’ll see of them.

Maybe not quite that bad, but after July 1, you’ll have to plan ahead and ration your time carefully, between errands and housekeeping, to get time with people outside of the hospital. (I have to plan for a week to get to the store for bread. Maybe I’m worse at time management than some other people.) Having only four days off a month, and those randomly assorted depending on your chief’s whim, makes it difficult to get things done outside of the hospital. Again, maybe I lack willpower; but I am not good at getting home from work, and setting out to clean the house, wash the dishes, run the laundry, and take out the garbage, before bed, instead of sitting down to read or get on the internet. One of the other female residents lamented the other day, “It’s not like we wear anything but scrubs; so why are there piles of laundry all over my house?” And we all said, “Yes.”

Anyway, enjoy your last two months.  <evil grin>

Since this is what I’ve been asked most often, we’ll talk first about good books to read in the month or two you have left, and also in the first year of residency.

Right now, I would recommend getting started on a basic surgical textbook, like Schwartz, Sabiston, or Greenfield. I’ve been using Sabiston this year, and it’s ok, but I was recently pointed towards Greenfield, and I like it much better. The chapters are a more manageable size, and the writing overall is better organized and more focused on useful information. These books will give you a lot of basic science information: some anatomy, a lot of physiology and pathophysiology, and the decision-making tree, how to diagnose, how to treat, when to do surgery, when not to do surgery. This covers the information you will get pimped on as an intern. I started to say it will give you the information you need when admitting a patient for surgery; but actually it’s way more information than you need on a day-to-day basis. One of my chiefs loves to advise us to read for one hour every evening. It seems like an impossible goal, but the more you can read at least a small amount on a regular basis, rather than sporadically, the better off you will be. I realized this after the ABSITE.  :) These books cover things like surgical infections, critical care briefly, trauma protocols, and medical issues in surgical patients, so this is probably the best place to review basic medicine from a surgical perspective.

Regarding the ABSITE, the surgical intraining exam given in January: some programs care more about it than others, but it does seem that fellowships will look at your scores. That’s what I hear from the residents who were interviewing this year. The absolute best book, beyond regular reading, is The ABSITE Review Book. There’s a second edition out this year. You need to start reading this a few months before January – October might be good – because although it’s a thin book, it is so crammed with information that you will not be able to absorb it if you try to rush through it in the month of January.

If your program has interns in the ICU much, The ICU Book by Marino would be valuable. He has some idiosyncrasies, but he explains physiology better than any book I’ve ever read. He goes through every aspect in detail: cardiovascular, respiratory, electrolytes, infections, and gives the reasons behind (or against) common practices.

Other than that, once you get into residency, you should have a surgical atlas to refer to, at least the night before cases. Some people (better disciplined than me) read these for recreation, and as a result sound extremely intelligent on rounds. A very basic one is Zollinger’s Atlas of Surgical Operations. There are many others, in more detail. Mastery of Surgery is a two-volume book (best found in the library; not a good way for interns to spend money) which both gives extreme details on the conduct of an operation, and most of the possible variations, as well as a brief overview of the pathology and diagnosis. If you have time, this would be a good one to read before an operation. For general information, I recently became enamored of Chassin’s Operative Strategy in General Surgery. This book starts at the beginning, as in how to tie knots, why to tie knots, and so on. It tells you all kinds of secrets which people seem to assume you ought to know, but will never think to tell you, and explains how to approach a problem, as well as the specific steps of many operations. Be careful, because it covers a lot of archaic operations that it would not be a good use of time to read much about. Later, when you’re senior enough to get called for the emergency Billroth 1 or 2, you might like to read some of these chapters again.

That’s really it. Overall, I’d say you’re better served by picking a few books and trying to read all the way through, and studying specifically the areas that you currently have patients in, than by trying to read all possible books. Not that you’ll have the time or energy for that after long.   :)  Oh, and UpToDate is wonderful, if your hospital has access. You’d be surprised how much surgical information is covered there. If you’re going to buy one or two books, I’d say Greenfield (if your program isn’t planning to give it to you – a lot of programs will provide the interns with one or two textbooks), and The ABSITE Review Book.

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