4 Days into Residency...

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Cardiac Amyloidosis

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So I am a new PGY-1 in an internal medicine program..

Is it just me, or does residency not have a lot of teaching? I know it's only been four days, but there has been a lot of teaching opportunities missed in my opinion. For example, we have had patient discharged and I didn't really know what the senior or attending look for when making that call. Or there will be patient's CBC labs that are all low, yet just get ignored. Little things like that.

Is residency just about having a great memory and being able to remember every little detail about 10+ patients for rounds (I don't know how my senior manages this lol), and then studying on your own time? I don't mind studying alone (I've been studying for hours every single day since I have started), but it would be nice to maximize the 10-12 hour work days getting educated more. Also, it would be nice to spend more time with the attending than just rounding for 2-3 hours.

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So I am a new PGY-1 in an internal medicine program..

Is it just me, or does residency not have a lot of teaching? I know it's only been four days, but there has been a lot of teaching opportunities missed in my opinion. For example, we have had patient discharged and I didn't really know what the senior or attending look for when making that call. Or there will be patient's CBC labs that are all low, yet just get ignored. Little things like that.

Is residency just about having a great memory and being able to remember every little detail about 10+ patients for rounds (I don't know how my senior manages this lol), and then studying on your own time? I don't mind studying alone (I've been studying for hours every single day since I have started), but it would be nice to maximize the 10-12 hour work days getting educated more. Also, it would be nice to spend more time with the attending than just rounding for 2-3 hours.

it varies from program to program, but right now your goal is to learn your way around your hospital, learning how to write a note and do orders in your EMR and not miss things on your patients. Learning how to remember every little detail on 10 pts for rounds IS your job...teaching will come.

and trust me, if your attending is completing rounds in 2-3 hours, thank your lucky stars!
 
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Are you asking about why the CBC is low or why someone is being discharged?

The new year is hectic as residents learn their new roles, interns learn a new system, and everything takes three times as long. In the first weeks, I think it's reasonable to focus on learning the system and your role. Once you become proficient at that, there will be more time for teaching. Re time with attendings, some have other duties (outpatient clinics, teaching responsibilities, committee meetings, research) so they may not be free. If you would like more teaching, sometimes we would have afternoon sessions for an hour or so where everyone in the team would look something related to one of the patients up and we would discuss our findings. Maybe that is something your team would be open to, maybe not.
 
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it varies from program to program, but right now your goal is to learn your way around your hospital, learning how to write a note and do orders in your EMR and not miss things on your patients. Learning how to remember every little detail on 10 pts for rounds IS your job...teaching will come.

and trust me, if your attending is completing rounds in 2-3 hours, thank your lucky stars!

I guess I am just anxious to learn as much as I can.

Any tips on remembering so much information about patients? My third year senior knows everything about all the patients without even looking at notes, meanwhile I have to keep checking my notes while managing 5 patients, is it just me or do all interns starting out have the same issue?

Are you asking about why the CBC is low or why someone is being discharged?

The new year is hectic as residents learn their new roles, interns learn a new system, and everything takes three times as long. In the first weeks, I think it's reasonable to focus on learning the system and your role. Once you become proficient at that, there will be more time for teaching. Re time with attendings, some have other duties (outpatient clinics, teaching responsibilities, committee meetings, research) so they may not be free. If you would like more teaching, sometimes we would have afternoon sessions for an hour or so where everyone in the team would look something related to one of the patients up and we would discuss our findings. Maybe that is something your team would be open to, maybe not.

I have asked a few questions but the explanations were not as thorough as I would have liked. Maybe I could propose that idea in a few weeks, I think it could help.
 
So I am a new PGY-1 in an internal medicine program..

Is it just me, or does residency not have a lot of teaching? I know it's only been four days, but there has been a lot of teaching opportunities missed in my opinion. For example, we have had patient discharged and I didn't really know what the senior or attending look for when making that call. Or there will be patient's CBC labs that are all low, yet just get ignored. Little things like that.

Is residency just about having a great memory and being able to remember every little detail about 10+ patients for rounds (I don't know how my senior manages this lol), and then studying on your own time? I don't mind studying alone (I've been studying for hours every single day since I have started), but it would be nice to maximize the 10-12 hour work days getting educated more. Also, it would be nice to spend more time with the attending than just rounding for 2-3 hours.

You should ask your senior/attending questions whenever you have them (within reason, I would skip the ones that you can look up on your own)...also you are learning/training by going through the motions everyday, results are cumulative (sorta like working out)
 
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I guess I am just anxious to learn as much as I can.

Any tips on remembering so much information about patients? My third year senior knows everything about all the patients without even looking at notes, meanwhile I have to keep checking my notes while managing 5 patients, is it just me or do all interns starting out have the same issue?

I have asked a few questions but the explanations were not as thorough as I would have liked. Maybe I could propose that idea in a few weeks, I think it could help.

are you asking about things you should be able to look up or things you couldn't find in some source (book, journal, UTD- not in that particular order)...

i used to fold a piece of paper lengthwise for each patient and would write my daily labs on it and on the inside would have a copy of the H&P and any pertinent imaging reports...sure it could make for a heavy pocket, but i could have a week's worth of labs and notes within easy reach. My intern year we were paper so wasn't out of the ordinary...i'm sure now the EMR may have better ways to organize things.
 
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You'll get better at remembering things as you gain experience because you'll know what is pertinent and what is not.

Much of being a doctor is just becoming familiar with things, and I often feel that formal teaching isn't as helpful as just seeing things over and over. You'll learn through osmosis and in a year you'll be amazed at what you know, despite your lack of formal teaching.
 
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are you asking about things you should be able to look up or things you couldn't find in some source (book, journal, UTD- not in that particular order)...

i used to fold a piece of paper lengthwise for each patient and would write my daily labs on it and on the inside would have a copy of the H&P and any pertinent imaging reports...sure it could make for a heavy pocket, but i could have a week's worth of labs and notes within easy reach. My intern year we were paper so wasn't out of the ordinary...i'm sure now the EMR may have better ways to organize things.

I ask questions like: "why did you look past these abnormal lab or physical findings?" or "why do you want to discharge this patient when they clearly have lung crackles on the physical exam". Things that come with experience I think.
 
So I am a new PGY-1 in an internal medicine program..

Is it just me, or does residency not have a lot of teaching? I know it's only been four days, but there has been a lot of teaching opportunities missed in my opinion. For example, we have had patient discharged and I didn't really know what the senior or attending look for when making that call. Or there will be patient's CBC labs that are all low, yet just get ignored. Little things like that.

Is residency just about having a great memory and being able to remember every little detail about 10+ patients for rounds (I don't know how my senior manages this lol), and then studying on your own time? I don't mind studying alone (I've been studying for hours every single day since I have started), but it would be nice to maximize the 10-12 hour work days getting educated more. Also, it would be nice to spend more time with the attending than just rounding for 2-3 hours.

I specifically remember my 4th day of residency being my lowest point of residency (from a "I'm in over my head and I probably should not have been allowed to graduate from medical school and oh my god how am I going to do this for the next 3 years and I'm probably dumbest person on the planet I wonder if my program director is going to find out I'm a fraud" standpoint)

Hang in there, it gets better. You'll never feel smarter than when you start 2nd year and meet the new interns and realize how much you have learned. It takes 3 years for a reason
 
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You'll get better at remembering things as you gain experience because you'll know what is pertinent and what is not.

Much of being a doctor is just becoming familiar with things, and I often feel that formal teaching isn't as helpful as just seeing things over and over. You'll learn through osmosis and in a year you'll be amazed at what you know, despite your lack of formal teaching.

I certainly agree with this. In the beginning everyone feels the same... overwhelmed, unable to remember details and feeling like they just aren't actively "learning". That's pretty much intern year, I'd say for most people.

At least in the beginning I'd recommend some sort of written notes/labs/rounding list system of keeping patients and labs organized. There are many different formats but you just have to find a system that works for you.

Personally, I think the whole EMR push has been somewhat of a disservice in the aspect that we now don't have to write everything out and thus miss out on that input into our memory. I'm not saying we should go back to paper necessarily, but as a med student and intern I remember hand writing H&P's and progress notes, including writing out labs and meds. For a lot of people just the act of writing it out helps you remember something. Now with EMRs much of the history, labs and meds are just copied in or carried over from a note so while you may glance at them I have found that I more frequently couldn't recall a particular lab as opposed to if I had written it. Personally I think this is just what we have to get used to, and may not be a huge issue as you can easily pull it up within a few seconds on your phone, but still interesting to think about IMHO.

In general though, you will get better at it over the next couple years with experience. You will learn what's important and what's not and thus what to put into memory.

Teaching can be variable and a lot of the practical aspects of the job you probably won't get any formal lecture in, but will learn from experience and seeing the similar cases over and over again, each with a slight twist. On the other hand, if there's something you aren't sure of, just ask. Now's the time. I'd much rather have someone ask why we did or didn't do something then just go along not knowing.
 
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I still really love the following comprehensive post on how to intern essentially: Help me turn things around. I rather wish i'd seen this when i was starting out.

It can take a while to 'see the forest for the trees". Is what one intern said to me about how they having trouble adjusting at first (which is universal). For me, it felt like, static and white noise. Ringing in the ears after, a mild concussion. Too many things going on to really process. Sometimes I didn't even know how or when to ask things, even that took adjusting.

I can relate to this
I specifically remember my 4th day of residency being my lowest point of residency (from a "I'm in over my head and I probably should not have been allowed to graduate from medical school and oh my god how am I going to do this for the next 3 years and I'm probably dumbest person on the planet I wonder if my program director is going to find out I'm a fraud" standpoint)
I had some bad imposter syndrome going on for me too.

The transition into being a resident is about converting the medical knowledge and more formalized or didactic teaching you received as a student into work. Textbook into practice, a bit like rotations, but on steroids. I can't remember where I heard or read it, but you don't really start 'critically thinking' (or piecing it altogether independently) as a doctor until you reach PGY2.

As a junior, it's getting used to doing logistical work, paper work or 'scut'. the seniors are the ones who are able to look at the bigger picture (as their job) as they're less overwhelmed with the 'details' that you may be swamped with. Like, how, when or where to submit or file a lab request. And as an intern, they don't expect much from you, other than to be reliable (doing the jobs you were asked to do, and not lying about things either if you missed or forgot something).

It may take weeks before you feel comfortable with knowing all your patients. or most of them. It's much easier with patients you see from start to finish, from the day of their admission to their discharge. Rather than inheriting a whole list that you've never met before and are mid way or towards the end of their treatment. give it time.

As for studying, you can do that on your own time. I usually save this for things I know I need refreshing my memory for, could be as simple as reading ECGs or ABGs. the first few weeks or months in though, maybe focus more on adjusting to the responsibilities and expectations of working as an intern. get comfortable. improve your efficiency. know your patients. and rest, when you have time for rest so you're refreshed for work the next day.

I agree with the post just above, "learning" or teaching is more on the job, and that accumulates definitely over time. commonest things are after all commonest. for instance, you get asked to review a patient, overtime you learn how to be more confident with doing reviews, and being faster and more efficient. you learn by doing admissions. it taps into what you learned as a student, but you learn to be faster and integrate more. you look things up less. it becomes second nature.

i used to get told to not memorize doses as a student, now I tell students that. because you end up writing the doses of some medications a few thousand times over as a resident. it's just pointless. i still carry around a small cheat sheet or cheat card that's pocket sized, with things like..warfarin reversal guidelines. but I don't really use it anymore.

whether someone will sit down and tell you about things, it's team and program dependent. what's invaluable as a resident is learning the practical side, learning to troubleshoot, working well on the teams, interdisciplinary relationships etc. It's just this whole other dynamic and shift.

if some lab value is very abnormal, you can always ask if your senior or supervisor is aware. usually they'll explain (in 1-2 lines) why they're not concerned, or give you some justification to put in the summary. sometimes, they may have missed it too. you're part of the safety net too, prior to a patient getting discharged back into the community.

TL;DR - you are not alone +pity+
internship can be mind numbing at first. :bang:
as the posts state above, it is indeed, learning about how to work as a resident. +pissed+and all it's joys. less about formalized teaching.
 
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I ask questions like: "why did you look past these abnormal lab or physical findings?" or "why do you want to discharge this patient when they clearly have lung crackles on the physical exam". Things that come with experience I think.

Consider rephrasing your questions. To me, "why did you look past..." or anything with the word "clearly" are condescending, especially coming from an intern. If an attending was asking that of a resident, that may be acceptable. Instead try "what do you think of xxx (abnormal lab values in this case)" and I would try to have your own suggestions like "is it due to sepsis, or a side effect of zosyn that they are on for the sepsis?"
 
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Consider rephrasing your questions. To me, "why did you look past..." or anything with the word "clearly" are condescending, especially coming from an intern. If an attending was asking that of a resident, that may be acceptable. Instead try "what do you think of xxx (abnormal lab values in this case)" and I would try to have your own suggestions like "is it due to sepsis, or a side effect of zosyn that they are on for the sepsis?"

Lol. I don't ask them that way, was just giving examples, I am respectful of course. Didn't mean to come off that way ha.
 
After my upper levels would present their plans on rounds I'd often chime in with "aw that's so cute." I was a very well-liked intern.
 
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