Don’t Make Me Be An Intern!
Had my first night of subintern call last night. We capped; I admitted 4 patients.
Man it sucked.
I fully recognize it will get easier: that I will get more efficient at entering orders, more comfortable with how detailed my H&P’s need to be, and more able to focus with less sleep. But still, it sucked, and will probably continue to suck.
Now, it wasn’t particularly difficult or anything, and wasn’t far from what I was doing as a medical student on my Medicine clerkship–I was seeing patients on my own, coming up with a differential, assessment/plan, writing the H&P, deciding management, etc. But man, it’s different as a sub-I. I’m essentially being treated as another intern on the team by my attending, resident, and co-interns–which is how I should be treated, and I’m glad it’s that way. But boy, just the slight upgrade in my status and responsibility has made me a wreck: being fully responsible for a patient’s orders, making sure they’re getting the right meds at the right doses, making sure the labs that I ordered get drawn, and the studies I ordered get done is a nightmare. Especially at 2 in the morning.
Things I am sadly but quickly learning:
- Take nothing for granted. Assume nothing. Even though they’re called “orders,” not “suggestions” or “pretty please requests,” it’s amazing how most of the ORDERS I wrote for (mostly labs that weren’t at scheduled lab draw times) didn’t get done, were completely just ignored, and I wasn’t even called about it. (It doesn’t help that labs on the computer system that have been drawn are described as “active,” whereas ones that are being ignored are labeled as “pending.”) So I wake up this morning, expecting my patients to have finished their rule-outs, since I scheduled their troponins x3 q8hr, and hey, they were never even drawn.
- If you don’t do it, it’s not going to get done. Sure, I have a fantastic resident who’s standing on the sidelines making sure I’m not forgetting anything, but it’s not like I have an intern co-following like you do as a medical student. If you meant to write for the daily chest xrays, or the stress test, and you just forgot, it probably won’t get done, and that means another day in the hospital for your patient (which is good incentive for you to not forget these things in the first place).
- It’s much easier to remember what we did for a patient when I’m writing the orders. When co-following, you’re kind of out of the loop on things. There’s this big stream of information that’s constantly going over your head, and when you go off to class for an hour or two as a med student, things can greatly change and you don’t really know about it until the next morning. But when you’re the one thinking, “Okay, what all do I need to do for this patient,” and you actually think it through and write or click which orders you want, it helps. A lot.
- My team is really trusting me with these patients. I know it’s just a month trial run, but when you look up on the floor whiteboard with patients names and the assigned intern name and pager number after it, it’s “Walker p11028,” not my resident or another intern. Yes, it’s annoying that I still need to call my resident to sign/co-sign any orders that I get called about, and that I can’t just give verbal orders, but while it’s still a Medicine rotation, it’s markedly different from the one you do as a non-sub-intern.
I think I hated mostly the fact that I didn’t feel like I was doing a very good job, on account of my lack of sleep. I really pride myself on the fact that I really try to do my best, and that I’m almost always on top of everything. But during call, I just felt the constant onslaught of work prevented me from having a chance to really think about the patients, read up about them in detail, or even really go through the differential. Most of my patients were pretty straightforward, so it wasn’t much of a problem, but I felt so pushed to constantly be getting orders in, and then seeing the next patient that I wasn’t able to really solidify patients’ stories in my head like I normally am. My presentations the next morning weren’t where I’d have liked them to be, forgetting small bits and pieces and having to go back. Perfectionist, guilty as charged, but I don’t like the feeling of being unsure if I’m providing the 100% best care to my patients, only providing good enough care to get them admitted, stable, and start initial treatments. (Maybe this is just the way call days work, I’m not sure.)
Old school docs and your ragging on the 80-hour work week be damned: interns on little sleep who’ve admitted patients all night, who are writing orders at 2 or 3 in the morning is, in the best of worlds, sub-optimal, and in the worst of worlds, dangerous. Having run around all day and night long, with patients’ stories and allergies and medications confused in your head, and then trying to write orders on them is awful. The mental poop that was coming from my brain was so foul and uncontrollable that it took easily twice as long for me to focus and concentrate to think through my patients. After 3 hours of sleep, the fog and haze was truly no better: I would sit down at a phone, desk, or computer and stare blankly, trying to remember what I was supposed to be doing. I wasn’t particularly sleepy or tired, just with a profound inability to focus. I hated being so out of control of my head, since it’s normally so easy for me to power through things.
It’s not the workload of the resident that’s the taxing part–all of us have pulled our all-nighters, with diminishing returns as the night carries on–it’s the frequent interruptions and constant shifting of attention. If you could just focus on admitting one patient at a time, it’d be great. But at the same time you’re admitting one patient, you’re gearing up, overhearing that your next one has just arrived in the ED; you’re getting a page that a patient needs pain medications when he’s already written for them; you’re trying to ignore your stomach that’s asking to please find something to feed it, while trying to concentrate and remember which is the antibiotic that covers urinary tract infections and which is the one that doesn’t.
I think I can see where Panda is coming from sometimes now. He writes about his frustration with patients, hospitals, and residency training, and from my N of 1 call night, I kind of get it. (Now, this does not mean that I agree with his solutions or placing of blame, of course–it’s not a patient’s fault that the system is messed up, or that they got sick at 4am–but you go through this and think, “God, there has to be a better way.”)
Enough bitching and ranting, as I’ve already talked several people’s heads off today, and now yours, too. Time for bed, and to hopefully work on getting my two other patients discharged: I’m on call again on Saturday.
OK, so, all these fatigued fuzzy-headed med students, interns, residents, fellows, etc. out there…running on no sleep…..many caffeine-addicted, or at the least, dependent.
Sounds like shift-work sleep disorder to me. Sounds like modafinil (Provigil) time.
I can’t believe that this stuff isn’t widely (WIDELY) used in this setting - it would almost be worth sponsoring research to show that it reduces error rates in fatigued medical professionals. Sure, it’s $8/tablet, but that’s two lattes for 20 hours of alertness.
E
this reminds me very much of my first experience being the primary on a patient.
some words to live by: Trust but verify; there are assassins around every corner; sleep any chance you can; sit whenever you can.
it was you first night on call. it gets easier. you get more efficient. call is part of most of medicine. those who like it are sick. 24-36-48 hour shift/calls truly suck. this is really not an 80hr work issue, because the restrictions don’t prevent “call”. many specialties routinely do this as attendings (no protected by 80hr work week). hang in there, you will get more efficient the more patients you see. with efficiency comes sleep. zzzzzz
You always have to think on the positive side or else you will be killed! Look what you just accomplished! Look how far you’ve gotten! Remember when you were just a pre-med undergrad?? The next time you try, it will be a little easier and you will be a little more efficient! My longest shift as a nurse (in the hospital, atleast) has been 8 hours. That right there is enough to knock me out (i am a sleepaholic). I can’t imagine doing 24/48/72 hours! I would cry! What helps me is I always carry around a candy of some sort (Spree, skittles - anything you don’t have to eat all at once) because as I’m rushing to the next room I can pop some and get my blood sugar up a little to hold me over.
You wouldn’t be placed in this position if you weren’t adequate. It’s easy to forget as a student/new doc that you’re not expected to be perfect. You’re supposed to be slow in order to get things right. If I had a new Doc speeding through things I would be worried they’re missing something.
Also, don’t be afraid to ask the nurse what s/he thinks. They’re the closest to the patients and had to go through medical classes too! :)
I personally love it and feel like my patients are getting the best care when a doc confers with me on planning.
-Dana Charlee
You need to start yelling at the nurses if htey dont follow your orders. Yes, nurses, they are ORDERS, not suggestions. If I write a fucking order, I expect you to fucking do it.
Now, once every 5 billion patients or so, I make a mistake with an order. Under that circumstance, you dont just ignore it, you FUCKING PAGE ME AND TELL ME WHY YOU ARENT FOLLOWING THE ORDER!
When did it become acceptable for nurses to just ignore orders for no good reason and not communicate that decision to the intern/resident/attending? Please help me understand that.
Take nothing for granted. Assume nothing. Even though they’re called “orders,” not “suggestions” or “pretty please requests,” it’s amazing how most of the ORDERS I wrote for (mostly labs that weren’t at scheduled lab draw times) didn’t get done, were completely just ignored, and I wasn’t even called about it. (It doesn’t help that labs on the computer system that have been drawn are described as “active,” whereas ones that are being ignored are labeled as “pending.”) So I wake up this morning, expecting my patients to have finished their rule-outs, since I scheduled their troponins x3 q8hr, and hey, they were never even drawn.
You mean you entered the order and they were ignored by the human beings while digitally displayed as “pending?” Were the orders entered into a CPOE system?
In any case, your organization has serious workflow issues if something as critical as labs are dependent on over-tired subinterns acting as watchdogs.
And I mean, serious workflow issues of the kind that result in torts.
Whew, you’re bringing back some bad memories…
My only advice is not to rag on the nurses too much. They’re working in the same messed up system and are probably over-worked and underpaid too.
One day, they just might be your best friend and save your ass.
Also, I never thought it was the hours. It’s how full they have become. My worst intern mistake was missing an MI as plain as day on a 3am ECG. But I had just gone 50 hours on 5 hours sleep and my resident was being an SOB about it.
In fact, the ward nurse got me to call the cardiologist early and we got the patient in to the unit about 5 minutes before the crash. Patient pulled through…
The most I ever learned was after hours, but my teachers never had to work as hard as I did in the 80’s and I can’t imagine how much crazier call nights are now… Nobody can function without a few hours of sleep.
Boy, do I feel your pain. At the beginning of my intern year, I never imagined that any of this would really get better with practice. But it does: as you go through your intern year, you’ll get better, faster, and more comfortable doing everything on that list of yours–including handling craziness in the middle of the night. Also, as you get to know and trust/be trusted by the nursing and auxiliary staff you work with, things will run more smoothly, and you’ll get fewer phone calls (sometimes).
Even in my second year, I’m still developing new strategies to handle challenges to personal organization, but I’m about a thousand times more adaptable and can remember a whole lot more stuff at one time than I ever could as a med student.
Your brain is extremely plastic. You’ll be amazed–and quite pleased, I think–at how it grows.
Good luck!
1. type, don’t dictate your H&Ps. Print them out for rounds.
2. interview patient (15 minutes top), then write orders, then do H&P.
3. Always have a protein bar in your pocket.
4. Nurses are leverage. They can be used to your advantage, or they can turn against you. Be smart.
5. An AI admitting 4 patients their first night is probably too many.
b
Congrats on surviving your first night! As an intern (or someone pretending to be one), any night when all of your patients live to the morning is a good night. An excellent night is when you’re medical management actually lead to that outcome …
After reading your post, I went back to read my own blog about my first night as an acting intern. It’s amazing to see the similarities — ordered tests that didn’t happen (and we didn’t hear about it), being flummoxed on rounds the next day, the constant interruptions, the seemingly easy questions from nurses that take time to answer, having to get your orders co-signed … We ought to compile these into a guide: “What to expect on your first night on call”
I’ll echo what others have said: it gets easier. You will eventually forget that you used to have to look up the dosing of Zofran, or whether to order a plain film vs CT to rule out SBO, etc.
But the anxiety takes on new forms: as a new second year last month, I didn’t have a senior to review my admissions — if I missed something on my H&P, it would go undiscovered until the next morning. Did I overlook something important? Order a beta-blocker for an asthmatic? Nitrates for aortic stenosis?
Scarily, in less than two years, I’ll be the attending, the final backstop, the last word in diagnosis, the person who is supposed to teach and take care of patients. Enjoy the security of your sub-I — the pressure builds from here (and so does the sense of confidence and accomplishment).
You know whats crazy? I’ve felt like this just working as a secretary in general practice. And it scared the crap out of me when i realised that this was how it was going to be when I had peoples lives as my responsibility.
I experience empathy for you, because you are new. I know that feeling of “feeling” like you are not doing a good job.
I was an honor student in nursing school
and got to the floor…knowing nothing.
You are a wreck for now and that is ok.
As for H&Ps here is the most creative impression I found yet on one of my patients. (I may be easily amused.)
1.Ascites secondary to #2
2.Cirrhosis secondary to #3
3.Alchohol Abuse
4.Respiratory insufficiency secondary to #1
Written by my favorite Zorro MD-who is a generic Zorro who stands for any impressionable,trustable, funny, teaching MD.
Well, I am writing to much on your space, I think I will go write my own post. My deepest apologies.
Hang in there!
I agree with Chris’s comment, someone should compile all these kinds of experiences into a helpful “Top 10 Things to Watch Out for On Your First Night as an Intern”
Or would that be top 101?
[...] that was much better than last time. I went into call with one patient, came out of call with… one patient. Our team went into [...]
Thanks for reminding me why I have several back-up careers planned if it turns out I hate being a sleep deprived doctor.
Wow - love this site, makes me realize it is not just my lame incompetant hospital that screws labs, pt names, procedures, and everything else up! Oh the stories…
Other tip - type a generic template up and print it prior to rounding so all you do is add the vitals, exam, and labs. Update the template at the end of day or PRN (some pts never change).
Oh and bring RNs food - they have a thing for it if you haven’t realized it. And sweet talk EVERYONE, the cleaning people turn over the rooms, phlebotomy gets labs, IV nurse puts in lines, and techs get your vitals - any small bump and your road to easy recovry is ruined!
[...] of my demise have been greatly exaggerated, even though my first night of call as a sub-intern was incredibly, incredibly painful. It’s scary to actually admit it, but I… kind of enjoyed my Internal Medicine [...]
[...] after a heart-felt post on the Over My Med Body Blog described how it feels to be a sleep-deprived sub-intern, two major [...]