Happy new year, friends! It’s been so long since my last blog post. Normally, I’m sharing all the med school tea. I kept good on my goal of maintaining a growth-oriented, reflective mindset throughout intern year, but starting 2023, I want to start documenting my early physician years to have something to look back on! Enter, new residency tab on le blogge!
Table of Contents
Ok, the biggest surprise of 2022:
I matched to my dream residency program. The perfect one. I didn’t care about the prestige of the program. I wanted the perfect curriculum, culture, and schedule. To be at a residency program and LOVE my life as a resident, to feel supported, never judged when I called out sick, encouraged to report my hours honestly, urged to prioritize wellness – that was my dream. That is how I ranked my programs. That is how I judged each program I interviewed at. I cared about primary care, inpatient, outpatient, geriatrics, palliative care, underserved. And I am even surrounded by people who also care about what I care about. Could it get any better?
The second surprise: how much I love residency! I heard many horror stories about the first year of residency. What if I too, judged wrongly? What if the residency program turned out to be malignant and toxic? What if they tricked me, as they do so many? Thankfully, none of these anxious thoughts of mine held any merit. Intern year turned out to be stressful, emotionally taxing, yet… full of wonder, fulfillment, and joy. I know that my experience is far from universal and that many residents do feel like quitting…suicide amongst residents is too common and unfortunately, real. I hope that those reading this do not resent me, as I only speak for myself, but that they find the courage to speak up, share their experiences, advocate for change, and seek support. (Easier said than done, I admit).
What is an intern? What do you do as an internal medicine resident? What is internal medicine?
An intern is just a first-year resident. Residency is just a period of time where physicians are trained on the job, but they do everything a physician does does (and more, will elaborate shortly). My specialty is internal medicine (IM), which is the most common medical specialty! You treat general medical problems seen in adults (no kids or OBGYN), like heart failure, COPD. IM physicians are often just called internists. They can work in the hospital as a hospitalist where they admit patients overnight from the emergency department to care for them throughout their hospital stay, or work in the clinic as a primary care physician. It gets more complicated. If you choose to sub-specialize, like in gastroenterology or cardiology, then you no longer practice primary care because now you are a specialist and not a generalist. Residency training includes both time in the hospital and in the clinic, but mostly in the the hospital. For me, because I want to practice both hospital medicine and primary care, I applied to a program that has a primary care track. I spend 4 weeks in the hospital, then 2 weeks of primary care clinic, and it repeats.
Life in the Hospital
0630: arrive at the hospital
If you’re on an ICU rotation, you arrive at 0530 or 0600. The night team will sign out to you and let you know if anything happened overnight to your patients. Internal medicine doctors are often the primary doctors taking care of patients in the hospital. When you go to the hospital and need to be admitted/stay overnight, we’re the ones that become your primary providers in the hospital! As interns, you are the primary provider for the patient. You’re the first person the nurse, pharmacist, etc. calls for anything. Your senior residents (second and third years) are available to help you.
0700-0830: pre-round
Pre-rounding is what you do before the attending arrives for rounds. (Rounds is when you talk about each patient and discuss your plan for the day with the attending). This is where the doctoring happens. First step in pre-rounding: vitals. Are they stable? Do they need to go to the ICU? Then you look at labs, imaging, new test results. Are they improving? Worsening? Any new issues like a kidney injury? Evidence of pneumonia on the chest x-ray? Oh no, this patient now has a kidney injury. Why? You come up with a differential, which is a list of things you think it could be. Then you order tests that will help you figure out what’s going on. Other times, I just wait until rounds to order something, unless it’s a harmless medication like something for constipation. In general, I have an idea of what my plan is going to be based on labs, imaging, and how they looked the day before. But we never just treat the numbers, so we have to go see how they look. E.g., if their kidney numbers aren’t back to normal but they are looking swell, it’s not a reason to keep them hospitalized (it will improve with time).
You have about 1 hour to see all your patients. As an intern, the max number of patients you can carry is 9-10. That means if you have 10 patients, you can only spend 5 minutes with each because you have to be back in time for “rounds” with the attending. The average is 7 patients, so I typically spend about 7 minutes with each patient, not counting the time it takes to walk to their room. If I can easily find the nurse, I’ll chat with them and get their report also! In between walking to the next patient, I change my plan if I have to. Sometimes they look worse or better than I expect.
0830 – 1100: rounds
Sometimes, you have no idea what you want to do for a patient. What dose of medication, what diagnostic test to order, why this patient isn’t getting better. That’s why you run your plan by the senior resident (running the list) and have rounds! Rounds are for updating plans and learning! Attendings are full-fledged physicians who supervise us and use their experience to help us become better doctors. Your seniors will help you put in orders as you discuss your plan. While the other intern is presenting their plans to the attending, you can start working on your to-do list: page consultants (specialists to help you figure out what’s going on with a patient), update nurses about the plan for the day, put in remaining orders, etc.
1100-1300: Tasks, conference, lunch, new admissions
This is when everyone divides and conquers. The attending goes to see all the patients and the senior resident helps you discharge patients and helps you execute your plan. If you haven’t already during rounds, it’s time to finish your tasks. Write notes. Call family for updates. If you’re not on call and have time, you go to conference to learn and have lunch! It’s either an interesting case, new practice changing research article that just came out, or reviewing diagnosis/management of something bread and butter (like acute decompensated cirrhosis).
The hard part is, in the midst of doing all the above, if you are on call, you are also admitting new patients. This means, the ED has a patient for you that needs to be admitted (stay in the hospital) for more workup or management (more tests, treatment). You take over and it’s time to doctor again. Get the history, physical exam, formulate your differential, assessment and plan. If one of your other patients is very sick, they might code (have a cardiac arrest) or become unstable (rapid response) at any minute and you will need to go see them because you are the primary provider.
1700-2100: shift ends
When you’re not on call/admitting new patients, you can be off by 5pm. If you are on call, you leave around 7pm or 9pm, depending on your call schedule or patient load. The latest I’ve stayed is 10pm. A typical shift is 11-14 hours, 6 days a week.
Life in Clinic
Clinic is a great time. I work 8-5pm, 5 days a week. I get golden weekends, which is when you have both Saturday and Sunday off. Basically a normal, free weekend. I also have my own panel of patients. I am their primary care physician! You actually don’t have a senior resident that you run your plan by, just the attending. AND, AND I get to spend 20-30 minutes with each patient (we start seeing more patients as we progress through residency). Some people don’t like clinic because they don’t always get the best continuity of care or they just prefer hospital medicine. I love clinic because I get to talk to patients for longer, it’s always been a strength of mine, and I get to grow more independent! I also get to have a more normal life. I get to spend time with people. I get to go to the beach, you name it!
What I Dislike about Residency
Before I get into what I LOVE LOVE about residency, let’s get this out of the way first…
Hours
Self-explanatory. I’m lucky I only average 40-50 hours per week when I’m on clinic and 70 hours/week when I’m in the hospital. Some of my friends consistently work 90-100 hours a week or more because they are on call doing 28 hour shifts. Residency programs are notorious for their unjust labor practices. I truly cannot think of anything worse in terms of labor and pay than working just above minimum wage with no overtime after you just went to school for 8 years to save human lives. While I do not love every single aspect of residency training, I love the good more than I hate the bad. Make sense? I love what I do more than I hate the hours.
Politics
At times, evidence-based medicine is sacrificed for maintaining hierarchy and older styles of practicing medicine, which can be frustrating because you want to provide the best, highest quality of care that is rooted in evidence! Even though medicine has changed a lot, it can be challenging to oppose those who have more experience than you when you are an intern. Sometimes, you just have to smile through it and tell yourself that you will be different when it’s your turn!
Preconceptions about physicians
Historically (and to some degree, now) nurses and doctors didn’t have the best dynamic. In the past, physicians have treated nurses poorly. It probably still happens today. Because of this, it is understandable when occasionally, a nurse will dismiss your position as the primary physician for a patient. Most nurses I’ve worked with are wonderful though and I love when it when we all communicate well and can joke around with each other. It just makes the day so much lighter and improves patient care!
Lack of passion for patient care
Many are leaving healthcare because of the broken healthcare system in America and some choose to stay because there is no other alternative. For the latter who choose to stay, burnout is common and it can be disheartening and frustrating when working with people who no longer patient care.
Non-clinical tasks
Being asked to fax something or obtain records rather than focusing on my task as a physician can be frustrating!
What I LOVE about residency
Connecting with patients meaningfully
This one is obvious! In the hospital, I unfortunately spend only 10-20% of my time seeing patients as you can gather from the above. In clinic, I spend 80% of my time with patients! As an aspiring geriatrician who loves to listen to stories and time travel to the older days with my patients, truly nothing makes me happier than to see a patient happy when they retell their stories. You learn so much. Your work is so much more meaningful when you know who you are caring for. It’s not just a lab test. It’s a lab test that could help you find answers for your patient’s problems. Sometimes we feel we are too busy to spend the extra five minutes with a patient, but I’ve never fallen behind because of that extra 5 minutes or regretted it. Those extra 5 minutes can be the difference between burnout/depression and resilience. Those 5 minutes are so worth it if you take it. Honestly, this might sound crazy, but if I’m feeling overwhelmed at work, I’ll just walk into a patient’s room to check on them, especially if it’s a patient who I’ve connected with before. We’ll talk about nothing medically related. Just two humans chitchatting.
Learning for life
We have almost daily lunch conferences where we discuss cases, review evidence-based medicine, and bread and butter medicine! We also learn so much on rounds with our senior residents and attendings who share their experience and wisdom. Our program’s primary care track is quite special because two times out of the year we have two weeks of primary care focused didactics! I’m just trying to be a sponge and soak up all the knowledge. I also learn a lot from the nurses, physical therapists, social workers, and consultants/specialists we interact with.
Support
Even though you are the primary provider for your patients, your senior residents are always available to help. You also have chief residents who can help with life situations. Great program directors will advocate for residents, which has been my experience! And we always have an attending available to call if we aren’t sure about how to manage something. That is the beauty of residency! Being a doctor but always knowing you have backup.
A Strong Primary Care Track
I feel blessed that I am part of a strong primary care track. Many people think that you’ll be sacrificing good hospitalist training, but that’s just not true. We do give up time in subspecialty rotations, but that’s because we aren’t interested in sub-specializing and want to do primary care! We still spend the same amount of time on the hospital wards AND we spend more time in primary care clinic. It’s truly the best of both worlds. Not just that, our primary care program cares about social determinants of health and allows us to go into the community to volunteer and bond with the community. All of our preceptors are so patient-centered and serve as such great role models. I’m convinced this is why I am so happy as a resident because I feel like I’m doing everything I love – hospital medicine, primary care, caring for under-resourced.
Stay tuned for more residency-related posts!
Dr. Kelly
