Thursday, July 10, 2008

Functioning at the Level of an Intern

A few of my med student rotation evals commented that I was "functioning at the level of an intern." Now that I'm an intern, I'm calling bullshit. There's just no comparison between being a medical student doing an inpatient rotation or a subinternship and actually being an intern. I predicted back in January that I really had no idea what it was going to be like, and I'm learning that I was entirely correct (and I called this, too).

  • As a medical student, I carried a pager, but I received fewer than 3 pages per day on average. Often, they were just from other med students, telling me we were rounding or asking if there was food.
  • As an intern, I am currently carrying 2 pagers (and I haven't yet been assigned a personal pager, but I'm trying to put that off as long as possible). When one goes off, I often can't tell which pager is beeping, so I usually check them both. One week in, and I hate being paged more going to the dentist. I'm developing a visible twitch and am prone to cursing outbursts when I get paged with my hands full or in the bathroom--perhaps I have Tourette's.
  • As a medical student, I was able to see all my patients, write beautiful H&P's and progress notes, keep track of my patients' to do lists, help my residents, and even read up on issues (gasp--learning!). Without sounding too conceited (I hope), I can say that I was a pretty good medical student.
  • As an intern, I feel like I barely have time to see my patients and put in their notes. When I get them in, I find myself making errors that I would have pointed out as a student. Patient A didn't get put on DVT prophylaxis. Patient B is on a zillion anti-cholinergic meds and is confused (not ordered by me, but not discovered initially). In completing Patient C's negative workup for stroke, we discovered a past medical history totally unknown to me (and indeed, the rest of the team) that actually explains his symptoms better. I forgot to order Patient D's nebs, until I listened to their chest this morning and thought Oh geez, they sound like junk. The errors are multifactorial: I'm new, the team is new, I don't know the computer system, half the time I didn't admit the patients and the error began in their admit orders, I just didn't catch it, I'm exhausted, etc. I feel responsible for it all, though, which I have to watch out for. It's useful to be responsible for my patients and be thorough, and learn from my mistakes; it's not useful to get so upset about minor things that I get flustered and forget big things.
  • As a medical student, I could get the history and physical and defer all questions of workup or treatment to the doctors.
  • As an intern, I AM one of the doctors, and it sounds weirder to say I'll have to go talk to the OTHER doctors first. It's like I'm saying, I'll go talk to your REAL doctor. I'm only pretending.
Other weird things:

I often find myself prescribing things to patients I don't know when I'm on call. I field questions like Mr. G has constipation, Mr. X has nasal allergies, Mr. Y is on heparin drip and has a PTT of 75, should I bolus? It's totally bizarre to me. If my husband asked me for medication for allergies, he can go to the medicine cabinet or the store and get it himself. In the hospital, we take that away from patients, and they're totally dependent upon those of us with those magical "MD" initials that give us control of their allergy medicine, Tylenol or Advil for headache, and the all-important constipation meds.

I gripe about the constipation thing, but actually, every patient in the hospital is likely to have trouble going poo. Hospital food isn't well-known for its high fiber and whole grain content, we put patients in bed and restrict their fluid intake, and tell them they can't get up to walk without assistance, lest they fall and break a hip. All of these factors = no poo. Honestly, if I were doing a better job of prevention with stool softeners and ambulation orders, I might have fewer problems with this. What I just find truly odd is that these pages are so frequently timed at 2-3 am. Seriously, I have never been so constipated that it woke me from sleep in the middle of the night. (Now, if they have insomnia, AND coincidentally feel constipated, that I can fix). I can give medication for constipation, but unless I write for an enema it's not going to magically produce poop within minutes. I still think that unless the patient is having pain, or is post-op from belly surgery, there's no reason for the 3 am constipation page, so long as the patient is clinically fine.

Also, this morning I got a page at 6:30 am for ordering air mattresses for two patients. Again, this was for patients whom I didn't know, and the page came in on the call pager, causing me a brief heart attack as I woke up and imagined a tPA candidate in the ER. I helped take care of it, and I was as nice as I can be when I'm awakened (I would have been getting up within about 5 minutes anyway), but I just have to wonder--isn't this an issue that is better taken care of during the day? It's not like the air mattress people are going to arrive any earlier than 8 or 9 am to examine their consult requests. No, I'm not bitter. At all.

I told my dad earlier, being an intern is a very odd combination of having supreme responsibility and having no responsibility (where being a med student, you really have few responsibilities). On the one hand, all my plans come straight from an upper level. I don't know diddly squat, other than to say "uh, stroke labs and an MRI?" On the other hand, I get paged about heparin drips and people seizing and I'm responsible for making spur of the moment treatment decisions, often with no warning. Do I give Ativan to the guy seizing in the EMU, even though his seizure is over and he's off his seizure meds so that they might record his seizures? Do we give the heparin bolus prescribed by the protocol, or do we leave it alone on the drip? I make these decisions all night and I have no idea if I've made the right decision. I just try to use common sense (what little I have).

I'm down 3 calls, 3 left to go. I'm so glad that after Sunday, my calls start spacing out further, because I'm effing tired. In fact, I'm going to bed.


Dragonfly said...

Re: "every patient in the hospital is likely to have trouble going poo. Hospital food isn't well-known for its high fiber and whole grain content....."

That is so true. WRiting discharge scripts for EVERY patient which include lactulose or coloxyl+senna drives me up the wall. Then when in GP clinic I see every old patient on these (and wonder if this was ever discontinued after they were d/ced) it also drives me up the wall.
I often feel like writing "5+ serves of fruit and veges, daily. Water, prn. Legumes, 2-3 times/week". One day...

Tiny Shrink said...

sooooooo true.

Nibbler said...

Most annoying page to date:
It's about noon. I skipping on my way to noon conference (aka, free lunch) when pager goes off.
Nurse : "Doctor. We HAVE yo do something about Mrs X's nausea. It's so bad! And Zofran isn't doing ANYTHING for her. PLEEEEEASE, can you do something for her??"
Me: "I ordered Phenergan prn for her yesterday because I know Zofran doesn't help her nausea. Is she still nauseated? I saw her an hour ago and she said she's been fine since last night?"
Nurse (drama now gone from her voice): "Well, that's just what they told me at shift change"
Shift change is at 7AM. She hadn't even looked in at her patient.

Tiny Shrink said...

OMG, sooooo true. I was told this morning that my patient had a FEVER! I checked the computer and said, oh, was it higher than 99.1? Because that's what he's been running at for a couple of days, no real fever there.

"...Oh, that's just what I was told in report."

I've also gotten a few pages for requests for PRN meds which were already written. I'm not sure if they just feel I need to know, or what, but it's irritating when I'm admitting a patient to the ICU and I get paged because Mrs. X's hand rash hasn't improved and she's itching! Well, okay, then, give her the PRN Benadryl she's got written!