Dumb Intern Question

[JustPlainBill]

Ok - so I'm walking the stage on Saturday, finally after the 5 year option.

I'm receving a BUNCH of surveys and paperwork to get ready for the first day of internship. Amongst those surveys is an 'entry-level competency assessment'. Competency? Oh, you mean I am supposed to know and be able to do this stuff for real?

I am acutely aware, and the survey really helped point that out, of my incompetence. I mean, I'm ok at writing notes, doing basic heart-lungs-abdomen exams, neuro exams and script writing. I can present in general and generally have to problems putting my hands on people.

But as far as rectals (other than FOBT), Gyn, OB exams - not so fast. Forget placing a fetal scalp monitor. suturing - basic single ties, ok. mattress - not so fast. knots - ? pre-surgical assesssments - say, what?

My question - how much of this was I supposed to learn and am I way, way behind the curve already?

can somebody help me out here? Preferably an attending or someone in residency now?

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[gutonc]

No, you're not expected to know all this stuff. That's the point of an "entry-level competency assessment." They want to know what you know going in and what you know at the end of intern year and again when you finish. Don't panic.

 

[Law2Doc]

No, you're not expected to know all this stuff. That's the point of an "entry-level competency assessment." They want to know what you know going in and what you know at the end of intern year and again when you finish. Don't panic.

While I agree you shouldn't panic, I think you ought to know how to do at least some of the stuff you listed coming out of med school, in so far as it's associated with your field of specialty. That's what the sub-I's most programs require were for. If you are going into surgery, you ought to be able to tie a knot. If going into IM or EM, you ought to be able to rectal or pelvic exams. While you can learn this stuff in internship I promise you a lot of your fellow residents will be pretty solid at some of this.

 

[JustPlainBill]

While I agree you shouldn't panic, I think you ought to know how to do at least some of the stuff you listed coming out of med school, in so far as it's associated with your field of specialty. That's what the sub-I's most programs require were for. If you are going into surgery, you ought to be able to tie a knot. If going into IM or EM, you ought to be able to rectal or pelvic exams. While you can learn this stuff in internship I promise you a lot of your fellow residents will be pretty solid at some of this.

Agreed - I guess the real question is what level of competency is expected in each task. Por ejemplo ---

On an ER rotation, I was asked by a 2nd year resident to suture up a patient with an upper arm laceration. He ended it by asking," You've done that before, right?". As I had never taken a patient from 'laceration' to 'sutures in, cleaned up, bandages in place, ready to discharge', I answered no. Now, I had thrown simple sutures, had been trained in mattress type sutures and knew how to inject lidocaine and use epi to keep it local (but not on digits, toes, dangly things, noses and ears) but had never been instructed in how to properly cover an area of laceration. But, due to my interpretation of the question, I said,"No". With a look of contempt accompanied by a gruff snort of contempt, he questioned my 4th year status and then proceeded to gather supplies and give a brief amount of instruction on what to do....sorry, I'd never had to grab all the supplies and didn't know all the little things that would be needed, nor did I know where they were and rather than bluff my way through it and possibly injure a patient, I said, 'No'.

Now, I asked a classmate on the same rotation about it and he said he was in the same position as I was but would have said,'Yeah' and gone and bluffed his way through it.

I have done and am 'comfortable' with pelvics, FOBT, sutures, cervical swabs. In my OB rotation, I made the mistake of asking a patient if she was ok with me checking her when the intern told me to check for dilation. That was interpreted as trying to get out of doing the check, I was pushed aside and never asked again. I had one delivery in six weeks, but did deliver a lot of 'red babies'. I'm ok with what has to happen, but haven't practiced it a lot.

Am I wrong for wanting adult supervision, having learned that all sorts of unforseen adventures tend to occur when children are left to their own devices?

I don't like being thrown in the deep end when there's the possibilty that someone, i.e. a patient, can get hurt.

 

[glade]

That's lame. Generally, my feeling is if someone asks "do you know how to do ...?" they're prepared for the answer to be "no." Otherwise, why ask? That's a waste of everyone's time. If you really mean "just go do this," then just say it.

The OB anecdote is an example of the difficulty with the medical field. Everyone has their own way of dealing with things, but we're forced to supervise and be supervised by others. This often leads to being put in uncomfortable situations or situations where you're thinking to yourself "man, this is going to be one major s**tfest" going in to it. A lot of people justify this by saying "trial by fire, we all did it," but it really makes you question what the point of medical "training" really is.

 

[Winged Scapula]

I'm confused...you know how to clean, inject local, suture but were afraid you'd hurt the patient because you didn't know how to dress the wound?

There is no one way to dress a wound (ie, it doesn't matter if you use Dermabond, Steri-strips, dry gauze, a Telfa and Tegaderm, etc.).

Unfortunately, there will likely be MANY situations to come in which you don't know how/haven't done before.

 

[JustPlainBill]

I'm confused...you know how to clean, inject local, suture but were afraid you'd hurt the patient because you didn't know how to dress the wound?

There is no one way to dress a wound (ie, it doesn't matter if you use Dermabond, Steri-strips, dry gauze, a Telfa and Tegaderm, etc.).

Unfortunately, there will likely be MANY situations to come in which you don't know how/haven't done before.

I reread my post and realized that I knew what I meant but it didn't come out the way I intended.....

I meant to say that I knew how to inject (mechanics of giving an injection and gradually withdrawing while pushing down the plunger) and knew to use lidocaine with epi to keep the lidocaine local (with major exceptions listed - use lidocaine without epi there). I didn't know where (in terms of geography around the wound) to inject the lidocaine for adequate coverage to ensure a pain-free experience for the patient. Do I inject at the 4 points of the compass relative to the wound? Is that enough? Do I go with spacing the injections 2 cm apart 2 cm from the wounds edge at 360 degrees around the wound? I also didn't know what dressing were appropriate. In my surgery rotation, we pretty much used dermabond and covered with a 4x4 and tape.

Which leads me to my next point....since my school was not associated with a major hospital but had 'contracts' with a few hospitals and local physicians in the area, each of us had different experiences, by and large. I was never inculcated in the considerations for where to use what type and size of suture material. I actually wound up looking for a YouTube video and found one of an emergency room doc who did a 'we assume you know nothing' type of video. Of course, it was the ED experience that led me to do this which means I was a slacker and non-hacker in that instance....should have been self-motivated to get the knowledge that I didn't get on surgery....ding on me.

It's things like this that make me nervous about intern year. Things I'm expected to know but am either a) a little shaky on or b)haven't been trained in/exposed to....I'm ok with unknown situations where I have to cobble together pieces of my training to achieve an objective....it's when I've been trained in a haphazard fashion with pieces missing and then I get burned by it that gets to me slightly.....

 

[ShyRem]

If you know parts but not all, don't just answer "no". Say "think so - use lido w/ epi, suture, dress with bacitracin/neosporin/whatever, bandage. Should I inject every 2cm from the inside of the wound around the edge or just 4 points? And do you have a stitch and suture material preference? And should I grab the stuff or does the nurse set me up for sutures?" This gives them the opportunity to see what you know, what you're comfortable with, and adjust your thoughts. And you get the opportunity to learn and not go through that again at that institution. If the nurse sets you up, follow them around to see where stuff is at. If you should grab your own but don't know where it is, ask a tech or one of the nurses. They'll teach you where to find stuff so you don't look like an idiot to your resident/attending, and you'll look like a rockstar. If you bring them coffee or chocolate later for helping you out you'll all be happy.

As for looking like an idiot as an intern - I've seen lots of interns do a LOT of really REALLY stupid things. And I'm talking REALLY stupid. I know I'll make my fair share of dumb errors, but I can't be worse than what I've seen.

 

[gutonc]

It's things like this that make me nervous about intern year. Things I'm expected to know but am either a) a little shaky on or b)haven't been trained in/exposed to....I'm ok with unknown situations where I have to cobble together pieces of my training to achieve an objective....it's when I've been trained in a haphazard fashion with pieces missing and then I get burned by it that gets to me slightly.....

This is when you go to your upper level/fellow (although it sounds like you're doing FM so no fellows)/attending and say "hey...I need to do X on Mr. Jones. I've done a few in med school but it's been awhile. Can we review it and can you come supervise me while I do it?"

This should really be the standard (and since the attending is responsible for what you do, how you do it and what happens if you F it up, s/he should always be aware that you're doing it and preferably be there) but isn't always the case. You should always have some supervision at the beginning of intern year though. Worst case scenario, see if it's on the NEJM procedure video list and watch that first.

 

[JustPlainBill]

If you know parts but not all, don't just answer "no". Say "think so - use lido w/ epi, suture, dress with bacitracin/neosporin/whatever, bandage. Should I inject every 2cm from the inside of the wound around the edge or just 4 points? And do you have a stitch and suture material preference? And should I grab the stuff or does the nurse set me up for sutures?" This gives them the opportunity to see what you know, what you're comfortable with, and adjust your thoughts. And you get the opportunity to learn and not go through that again at that institution. If the nurse sets you up, follow them around to see where stuff is at. If you should grab your own but don't know where it is, ask a tech or one of the nurses. They'll teach you where to find stuff so you don't look like an idiot to your resident/attending, and you'll look like a rockstar. If you bring them coffee or chocolate later for helping you out you'll all be happy.

As for looking like an idiot as an intern - I've seen lots of interns do a LOT of really REALLY stupid things. And I'm talking REALLY stupid. I know I'll make my fair share of dumb errors, but I can't be worse than what I've seen.

Thanks, ShyRem ---

I'm seeing where vestiges of my upbringing (medicine is for smart people - we're not that smart, it's not for you) are lingering and making me timid. I like that approach and will use/adapt it......I've learned something today....

 

[JustPlainBill]

This is when you go to your upper level/fellow (although it sounds like you're doing FM so no fellows)/attending and say "hey...I need to do X on Mr. Jones. I've done a few in med school but it's been awhile. Can we review it and can you come supervise me while I do it?"

This should really be the standard (and since the attending is responsible for what you do, how you do it and what happens if you F it up, s/he should always be aware that you're doing it and preferably be there) but isn't always the case. You should always have some supervision at the beginning of intern year though. Worst case scenario, see if it's on the NEJM procedure video list and watch that first.

Thanks -- based on what I read from ShyRem's and your comments, I'll be ok. Oh, and thanks a whole lot for the NEJM procedure site....I'll be perusing that for sure....

 

[2Sexy4MedSchool]

"In my OB rotation, I made the mistake of asking a patient if she was ok with me checking her when the intern told me to check for dilation. That was interpreted as trying to get out of doing the check, I was pushed aside and never asked again. I had one delivery in six weeks, but did deliver a lot of 'red babies'. I'm ok with what has to happen, but haven't practiced it a lot."


OK, I'll bite. What's a "red baby" and how does that delivery differ from the typical blue/pink/meconium-covered varieties? 2S4MS

 

[smq123]

"In my OB rotation, I made the mistake of asking a patient if she was ok with me checking her when the intern told me to check for dilation. That was interpreted as trying to get out of doing the check, I was pushed aside and never asked again. I had one delivery in six weeks, but did deliver a lot of 'red babies'. I'm ok with what has to happen, but haven't practiced it a lot."


OK, I'll bite. What's a "red baby" and how does that delivery differ from the typical blue/pink/meconium-covered varieties? 2S4MS

I'm assuming he means that he delivered a lot of placentas, but no ACTUAL babies.

 

[MR1]

yeah "red baby" = placenta. The great pastime for med students to deliver.

Never ask the patient if it is okay to do something, patients think that means you don't know what you are doing. You just say "my name is such and such and I am here to do whatever"

As far as saying no to the suturing thing, you can always tell them you have only done a few and ask for help getting set up and then ask specifics that you are not sure about, ie dressings, where to inject, etc.

 

[bambi]

Never ask the patient if it is okay to do something, patients think that means you don't know what you are doing. You just say "my name is such and such and I am here to do whatever"

.

And you don't have to add an "is that ok?" to that? We would be killed for that here!

 

[DaveinDallas]

.

 

[humuhumu]

I somehow managed to get through 4 years of med school without doing a FOBT. I didn't avoid it; someone else always did it before I had a chance. Now it's on my list of "things to look up" before I start intern year in a month, so I don't feel completely clueless...

 

[cartoondoc]

I went to a med school where you had to ask permission to breathe on a patient, much less do some kind of procedure on them. Came out of med school feeling like a total idiot about procedures.

Did my internship at a county hospital where I usually didn't speak enough of the patient's language to double check if it was OK if I, the intern, did the procedure. I started my first day the emergency room barely knowing how to suture, finished out the day as the world's leading expert. Don't worry, internship has a very steep learning curve, and you WILL learn this stuff, like it or not. It's kind of like being thrown into an ocean when you're not such a good swimmer.

 

[Law2Doc]

... It's kind of like being thrown into an ocean when you're not such a good swimmer.

Add a few sharks to the scenario and I agree with the analogy.

 

[kemper6036]

"In my OB rotation, I made the mistake of asking a patient if she was ok with me checking her when the intern told me to check for dilation. That was interpreted as trying to get out of doing the check, I was pushed aside and never asked again. I had one delivery in six weeks, but did deliver a lot of 'red babies'. I'm ok with what has to happen, but haven't practiced it a lot."


OK, I'll bite. What's a "red baby" and how does that delivery differ from the typical blue/pink/meconium-covered varieties? 2S4MS

i didnt know either....thanks for taking one for the team!

 

[gutonc]

I somehow managed to get through 4 years of med school without doing a FOBT. I didn't avoid it; someone else always did it before I had a chance. Now it's on my list of "things to look up" before I start intern year in a month, so I don't feel completely clueless...

What is there to look up?

You stick your finger up someone's butt, you smear it on a card, you either squeeze a drop of developer on it (that your senior resident has been hoarding since s/he was an MS3) or you send it to the lab. If it's positive (minutes to days later, depending on which route you took in the 2nd step), you call GI who starts by asking what the DRE showed, then mocks you for checking the FOBT since it's always positive when you do it by DRE (not entirely true, but true enough) and says to send the patient see them in clinic in 1-4 months.

In 4 years of residency+fellowship, I have done a grand total of 2 stool guiac tests. Both were positive, both had clean colonoscopies/EGDs. If you have a reason to believe there's GI bleeding, a colo +/- EGD is in order, an FOBT is a huge waste of time. If you are just rectalizing someone because "that's what we do" or you can't figure out what's going on, you're going to be misled by the results of the FOBT.

 

[Winged Scapula]

you call GI who starts by asking what the DRE showed, then mocks you for checking the FOBT since it's always positive when you do it by DRE (not entirely true, but true enough) and says to send the patient see them in clinic in 1-4 months.

 

[the fat man]

When I rotated on GI the fellow told me if I should learn only 1 single thing from being there for a month it should be "Don't EVER call a consult for guaiac-positive brown stool."

 

[Law2Doc]

When I rotated on GI the fellow told me if I should learn only 1 single thing from being there for a month it should be "Don't EVER call a consult for guaiac-positive brown stool."

Um, that's going to be one of the few GI guys who is going to be broke then. They make their living on these consults. Consults may seem like a pain to residents/fellows, but that's $$$ to the attendings. They get to do a procedure, they get paid. Every positive hemocult test is money in the bank. They WANT you to call that consult. You have a positive result so that's going to be enough justification to get an insurance company to foot the bill for a further study to see why that result is positive, and rule out worse things than an overaggressive DRE. The fellow might not be interested in such consults, because he doesn't get a cut YET, but it's pretty short sighted to tell interns to cut off the gravy train. Heck, if I were an attending, I'd want interns to consult the hell out of me and let me decide what merited further action. You don't get a beach house by telling consults to dry up.

 

[the fat man]

Um, that's going to be one of the few GI guys who is going to be broke then. They make their living on these consults. Consults may seem like a pain to residents/fellows, but that's $$$ to the attendings. They get to do a procedure, they get paid. Every positive hemocult test is money in the bank. They WANT you to call that consult. You have a positive result so that's going to be enough justification to get an insurance company to foot the bill for a further study to see why that result is positive, and rule out worse things than an overaggressive DRE. The fellow might not be interested in such consults, because he doesn't get a cut YET, but it's pretty short sighted to tell interns to cut off the gravy train. Heck, if I were an attending, I'd want interns to consult the hell out of me and let me decide what merited further action. You don't get a beach house by telling consults to dry up.

I'm fairly sure the attendings my fellow reported to are on salary so they don't benefit from the extra work. Even so, it is absurd and unethical to call unnecessary consults. It's a waste of money for one thing, and there are complications for every test and procedure we perform. What if we perf someone's colon on a c-scope when that scope was unnecessary in the first place?

L2D, as for your gravy train, go ahead and practice out on your own in some community hospital, where you can staff the entire consult from chart review to procedure YOURSELF. But you have no right to make powerless underpaid fellows do your work, perhaps even HARM a patient on your behalf and then take the fall for it, so you can buy a bigger boat. I seriously find it hard to believe that someone who claims to be a resident always defends the worst abuses of our training system without fail.

 

[JustPlainBill]

Well----turns out to not have been an issue. I guess it was just a real bad case of pre-mission jitters....

2nd week of surgery and have had two attendings compliment me on my suturing and dissection skills. They may have just been being nice, but neither corrected my work. I spoke up and asked questions where appropriate and no one laughed or called me an idiot, they just trained me. Having a great experience so far.

Clinic has been pretty good. The main pain has been the EMR. Some days I wish for paper and written orders, so much easier but this is the future....

All in all, no problems that a cold beer couldn't fix....

 

[Gastrapathy]

When I rotated on GI the fellow told me if I should learn only 1 single thing from being there for a month it should be "Don't EVER call a consult for guaiac-positive brown stool."

Just saw this.

Here's what I say:

FOBT is a CRC screening test. If you are using it for anything else, you are wrong.

However, once you've done something stupid and caused a positive test, we can't ignore it. There is no data for the rates of adenomas or CRC after an inappropriately obtained positive FOBT. So, I do want the call. But expect me to tell the patient that I cannot interpret the result and based on that, I'm recommending a procedure that may be unnecessary. And I will patiently explain to you (unless we've done the "really, you guaic'd a 25 yo with IBS, well that sucks" conversation before) why this made no sense.

Most housestaff are trainable. Some ED attendings and every Gyn NP are not.

 

[Apollyon]

Most housestaff are trainable. Some ED attendings and every Gyn NP are not.

I'm an EM attending, and get asked every shift about the rectal exam by the hospitalists. Every shift. I can't win. When I was a resident, and I called for a GI bleed, I was told that brown stool can have a hematocrit of 70 and still look brown, and, despite a precipitously lower H&H, hypotension, and tachycardia, I would be asked what was the guaiac (if it wasn't frank blood at that moment). And I trained at a name place.

I can't win.

(Well, except for the pancytopenic lady due to hydroxyurea, who had an ANC of 340 - I got to remind the hospitalist that, with ANC<500, rectal exam is contraindicated.)