Intern year as a transitional year resident
Intern year is a whirlwind, no matter what specialty you’re in. As they say, the days are long but the years are short.
If you’re anything like me, you’ll likely be very eager to get to your advanced specialty. Don’t get me wrong, intern year is important for radiology (and other specialties) for many reasons, including knowing why clinicians order certain studies, clinically correlating (*wink*) , and being a “real doctor” for a year, but that doesn’t make it any less difficult.
BUT, that just makes it that much sweeter when you start your next phase of residency, right?!
I’ll be talking specifically about my experience as a transitional year resident in this post and Wade will discuss his experience as an ortho intern in another post.
The medicine wards were my very first rotation, which was both a curse and a blessing. I am so grateful now that I started on wards since I was excited to hit the ground running, but at the time I was very overwhelmed. Not only did I have to figure out a new hospital, new EMR, and meet new people, but it was also the first time I was a full-fledged doctor. Hopefully, your upper level residents will support you and show you the ropes, because that makes a huge difference. I was lucky to have had an upper level residents who challenged me to be independent but also took the time to show me how to properly document, put in orders, learn doses of medications, etc.
In terms of the schedule, you guys know the drill from medical school! You’ll receive sign out from the night team around 6:30-7am, chart review and see your patients, and then round with the attending mid-morning. Sometimes you'll run the list with your upper level resident before rounds but not always. After that, you have the rest of the day to attend noon conference, put in orders, finish notes, follow up on tasks, call family, check up on your patients, etc. You'll likely run the list with your upper level resident mid-afternoon once you've had a chance to follow up on things after rounds. If you’re not on call and you’re not the late-stay resident, you’ll likely be able to leave for the day once you finish your work (however, this may depend on your program’s protocol, so ask about expectations early on). In this case, you'll sign out to your co-resident who is staying and you'll keep your pager and your computer with you when you get home so you can respond to calls and put in orders from home if needed.
*Tip: download Epocrates to help you dose medications! UpToDate, Hospitalist Handbook from UCSF Department of Medicine (app), and the OnlineMedEd intern guide/videos are helpful as well.
The most important thing I learned on wards (aside from the interesting pathology!) was that you have to take the initiative in order for things to get done. If your patient is waiting on acceptance to inpatient rehab and you haven’t heard about their status yet, reach out to the case manager for an update. If you consulted IR for a paracentesis yesterday but the patient still hasn’t received it, call IR and find out what the deal is. If you ordered a CT head for a patient 12 hours ago and radiology hasn’t taken them down yet, call them and find out why. Even though it can be frustrating, a lot of times you’ll need to do things yourself in order to see results. There’s usually a logical reason for why things are being held up, but if you investigate the reason, you can often expedite the process and get your patients what they need! And most importantly, be nice to ALL staff. Everyone, no matter what their role in the hospital, deserves your respect. Besides, you don't want to be known as the arrogant and rude doctor who looks down on others. Golden rule, people! Plus, you'll find that more people are more willing to help you if you are kind to them.
Slow down and remember why you’re here. As a resident, the days can be stressful, hectic, and you may feel like you don’t have time to complete all of your tasks. When you walk into each patient’s room, try to put blinders on and give them your undivided attention. Being in the hospital can be scary for many patients, and sometimes all they need is to feel like someone is listening. Even just spending an extra 5 or 10 minutes in the room to explain the daily plan or big picture can make a huge difference. I can’t tell you how many times I’ve been thanked for just spending a little extra time with my patients and updating family members on the plan of care. The little things can make a huge difference.
While the wards is the most common rotation that you'll have in a transitional year or preliminary medicine year, ICU is another one that you’ll likely have to complete. Before I started, I had a significant amount of anxiety about this rotation because I never had an ICU rotation (or anything similar) in medical school. However, I enjoyed this rotation so much more than I thought I would. While ICU tends to be one of the busier rotations with more difficult hours, you will learn so much on this rotation and truly get to practice medicine. You will have to do less of the “social work” aspect of medicine and will get to focus on the actual pathology. I had some amazing attendings and upper level residents (shout out DT and HT) who taught me how to do certain procedures and who gave me so many opportunities to learn.
Take every opportunity you can! If you’re a prelim or a TY you’ll most likely never get the opportunity to do a rotation like this again. Participate in chest compressions during a code, place central lines, and do whatever you can to get involved.
The ICU can be a very depressing place so make sure to take care of yourself too. If you need a moment to collect yourself on a hard day, there’s nothing wrong with excusing yourself to get out a good cry or just reflect. Trust me, we’ve all been there and some cases will hit you harder than others. You become very attached to your patients and their families and the emotions can creep up on you when you least expect it. Remember, you have to be your best self in order to be there for your patients. I found that writing about my experience helped me reflect and talking it out with someone you love and trust can be very therapeutic as well.
Electives are pretty self explanatory and the schedule often varies so I won’t go into too much detail here. But if you’re a prelim, I would encourage you to choose electives that are relevant to your advanced specialty! For instance, if you’re doing radiology, I’d recommend doing a radiology elective (if your prelim program has an accredited radiology program attached to the institution that is, otherwise you can’t- this is an ABR rule unfortunately), pulmonology, neurology, heme onc, GI, etc! Those going into anesthesia would likely benefit from pulmonology, anesthesia, and surgery electives in addition to ICU. Dermatology residents would likely benefit from dermatology, infectious disease, heme onc, etc. The list is endless! The list of electives will likely depend on what your program has available.
Ambulatory & Emergency medicine (EM)
Transitional years also require an ambulatory month and an EM month. The ambulatory month is essentially just an outpatient general medicine or subspecialty clinic, though it can differ based on your program. I was in a cardiology/primary care office for a month and based on my attending's preference I would see the patients first, check out to the attending before they saw them, we would go over the plan, and I would take care of the documentation. Again, what the ambulatory month entails is dependent on your program. It's very similar to your medical school rotation but you have more responsibility.
For your EM rotation, you will be assigned certain shifts and your role will likely depend on your attending. In my experience, I would keep an eye on the ED tracker and just started seeing patients based on urgency and wait time. After that, I would check out to the attending, they would see the patient, and we would come up with a management plan and disposition. Based on your comfort level, you can participate in many procedures including central lines, suturing, reductions, among others! There's always lots of action in the ED and I would encourage you to get involved, especially if your advanced specialty is procedural.
I had a love/hate relationship with night float, as most people do. This rotation can be extremely variable in terms of intern responsibilities so just be aware of that as I discuss my experience. At my program, interns are primarily responsible for covering the floor calls as well as admitting a few patients. On a typical night, I would receive calls from the nurses that I would need to respond to regarding pain control, unstable vitals, agitation/delirium, constipation, insomnia, clarification of orders, chest pain, etc. I would often run my plan by my upper level resident just to ensure that my thinking was reasonable. If the patient was experiencing new pain, had a new issue, or was delirious, I would often go see the patient and make an assessment for myself. Remember, trust but verify!
Getting a good sign out from the day team is extremely important and you need to know the right questions to ask them. Make sure to ask them about what they're okay with giving for pain, delirium, etc. and who are "watchers" for the night. This will not only make your life easier during the night, but it is also better for the patient, since the day team knows the most about them and their plan of care. I tend to throw in a short note describing what I did overnight if I had to go see the patient or treated them for something more complicated than simple issues like pain, etc.
In terms of new admissions, this is essentially just your typical H&P that you would do on day call. Do a full assessment of the patient and come up with their management. You will then sign out the patient to the day team at the end of the shift and they will take it from there.
If the night is slow, feel free to take a nap, do something you enjoy, or just relax! Nights can be tough, especially since you feel cut of from your family and friends since you sleep during the day, but sometimes it's nice not to have to worry about daytime issues at work.
*Tip: Both the Hospitalist Handbook app and OnlineMedEd intern year book are very helpful for nights.
Phew, this was a long one! Intern year is tough, no matter what specialty you're in, but do your best and take it one step at a time. As a prelim, even though you're only there for a year, make a good impression, work hard, get to know your colleagues, and do right by your patients. Who knows, maybe you'll cross paths with your co-residents in the future, especially if you stay at the same institution for your advanced program.