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.