This post by Ashley Rider, a second year EM resident, is for the all the band new residents starting their internship.
Intern year is special. We finally have the responsibility that we have been yearning for, but it is appropriately coupled with layers of protective guidance from upper levels, fellows, and attendings. The hours can be long and grueling, but they tick away surrounded by people that understand your challenges, offer support when days are tough, and inspire you to be your best.
Striking a balance between your resident duties and life outside of the hospital can be one of the greatest sources of strain during intern year. Finding the time to keep in touch with friends and family in far away places is exceedingly difficult. You will probably miss some holidays. Your work schedule may be incompatible with many important events. Stressors may feel like they come from all directions—patient care, residency requirements, student loans, car issues, apartment fixes, and your relationships. Meanwhile, you are expected to work toward mastering the specialty of emergency medicine.
You will be functioning on limited bandwidth every day, week, and month this year. Time must be prioritized.
Once a month…
♦ Streamline your life. For all of those monthly bills, activate automatic recurring payments. You would be surprised how quickly the 1st of the month sneaks up on you. Ask your landlord about alternative payment methods or direct bank transfers. If you have roommates, brainstorm ways to consolidate payments. The fewer minor tasks you have to remember, the more your cognitive faculties can be applied to other areas of your life.
♦ Allow Google calendar to be your best friend, by helping you keep your best friends. Plug in event reminders and birthdays. Make a habit of checking your morning email of calendar events to avoid tardy birthday wishes or Mother’s day cards. Put your shift hours into a calendar, and then share it with family, friends, and significant others so that they know when you are available. With the beginning of each month, map out your upcoming events compared to your work schedule. On the eve before a new rotation, allow yourself 15 minutes of quality time with the GCal to plan ahead.
♦ Make time for your classmates. Believe it or not, your co-interns may be the people you see the least as you are carted off to the obligatory off-service intern rotations. Some of my most cherished moments of intern year were my class dinners. On the last day of every rotation one person would coordinate an outing that allowed us to catch up while visiting new areas of our city. Your co-interns understand everything you are going through. Revisiting your special bond every few weeks might be revitalizing enough to plunge into the next month’s “new job.”
Once a week…
Establish routines for learning and wellness.
♦ Attend conference. This is five hours a week dedicated to your education. Be engaged! Take advantage of the protected time to learn from faculty, guest speakers, and peers. Bring ideas, bounce your thoughts, and ask questions. We only get this for 3 or 4 short years—don’t miss out! It is a tremendous component of our education with the unique flair of our residency program. That’s something CME will not offer in the decades to come.
♦ Keep in touch with family and friends. Vacations do not come often enough. Make a phone call to the parents, siblings, and friends that made you who you are. They want to hear how you’re doing! This may need to happen on the drive home, while folding laundry, or during an apartment clean. Put your emergency medicine multitasking capabilities to good use, and you will find the time.
♦ Reflect. Relax. Treat yo’self. GME requires approximately one day off a week. Set aside at least one hour on that day to do something that makes YOU happy. Take a walk, write, go to the gym, read, do Yoga, lounge in the park, hit the mall, or go for a hike. Whatever it takes to recharge and reset—you deserve a break!
Aim to give 100%.
♦ Sleep. Time is always going to be limited but sleep is necessary. Every hour of sleep debt you accrue will chip away at your potential as a learner and as provider of patient care. On those days you have to wake up at 4am, go to bed earlier! Sleep hygiene is key: put away electronics, keep your room dark, and avoid food/exercise/alcohol/caffeine before going to bed. In emergency medicine we also have to tackle rotating schedules and night shifts. Invest in dark curtains and an eye mask to get your needed rest during the day. The routine you develop this year will set you up for a career of shift work, so make them good habits.
♦ Read about your patients. Pick at least one patient per shift and peruse a relevant up to date article, book chapter, or residency resource. At the peak of your exhaustion, a few minutes at the end of the day may seem unthinkable, so practice “learning on go.” Look up articles as clinical questions come up and scan them when you find free moments (e.g. waiting to present to the attending, walking to your mode of transportation at the end of a shift, or during the 5 minutes before sign-out). Furthermore, don’t let that time spent go to waste. Be sure to organize your learning, whether in a notes app, on old-fashioned pen and paper, or through Evernote. Screen time will be limited this year, so try to find ways to learn that don’t involve your computer.
♦ Stuff is going to happen. You are going to have bad days. You might get a flat tire on the way to work. You might make a medical error. You might feel overwhelmed and utterly useless—it happens to everyone. But remember that this too shall pass, every day comes to an end, and tomorrow is a new start (this goes back to the importance of sleep!)
Brace yourself for the many challenges you will encounter.
♦ Prepare yourself for patients based on the differential for their chief complaint. Before you go to see him or her, have the top 5 most concerning diagnoses at the forefront of your mind. While interviewing the patient, collect all evidence that helps you to rule in or our these diagnoses, and formulate a plan from there. This active thought process will help you develop your practice style much more than a shotgun approach. Take a few minutes each day to follow up your patients. Did they come back to the ED after discharge? What became of them in the hospital? It will ultimately make you a better provider.
♦ Know your team. Nurses will save you and will frequently aid your decision-making. If you are worried about a patient, call rapid response and respiratory therapy. Social workers may be able to provide suggestions and resources that you didn’t even know existed. Call radiology to talk through an x-ray that you didn’t initially read correctly, because someday you may be the sole provider interpreting overnight films. Finally, remember all those dosages we never learned in medical school? Pharmacy will be your saving grace. If you are unsure about a medication interaction, dosing regimen, or the available of a drug, call your friendly pharmacist.
♦ Hypoglycemia is our Achilles Heel. For patients, always check a D-stick upon arrival. You can cure quite a few presumed altered mental statuses, or even CVAs. For yourself, recognize that glucose is the fuel for the brain. Keep a couple of granola bars (fun size snickers count, too) for that delayed meal or busy high acuity shift.
Keep a positive attitude.
♦ Learn something from every case you see. It might be an agitated psychiatric patient, but they, like all your patients, are in the emergency room as a last resort. Give them your best doctoring. Investigate all organic possibilities. Hone your communication skills with difficult patients while you have the time. Learn what labs to order and what paperwork to fill out. Know where the snacks are kept. Your R2 self will be glad you took the time to learn the basics. Everything you tuck away this year will make the road ahead less bumpy.
♦ Be humble. You leaned a lot in medical school, but remember this is only the foundation. Always develop a differential, even if you are certain of the diagnosis. Consider the input of every member of your team. Recognize when you were wrong, and use your mistakes to improve care of the next patient. There is always more to learn!
♦ May your every task be aimed toward taking good care of patients. Just don’t forget about yourself along the way.
For additional pearls straight from the chiefs, see the ALiEM post on residency secrets to success: https://www.aliem.com/2016/top-10-success-resident/
Welcome to emergency medicine. Best of luck with every month, week, day, hour, and moment this year!
Ashley Rider, PGY-2 Highland Emergency Medicine