What It Means To Be A “Good” Intern…

Now that I am a “senior resident” PGY3, and in my final year of internal medicine residency, I have come to realize how hard it is to be a “good” intern. Now that it is midway through August, I know the fresh interns are asking themselves, “How can I be a good intern?” or perhaps more realistically, “How can I not be a bad intern?”

These apprehensive thoughts are normal and expected and, in some ways, healthy, but do not let them get the best of you. After pondering the question of what it means to be a good intern, it has become evident that the answer very much depends on the perspective of who you ask. For example…

From the Patient’s perspective: An intern who sits down, listens, explains the plan and interprets exam findings, answers questions, and never rushes the interaction.

From the Med Student’s perspective: An intern who knows their name, includes them in educational tasks, treats them as a valued member of the team, does not overly “SCUT” them out, and sends them home when there is no longer a need for them to be there.

From the Resident’s perspective: An intern who is honest, efficient, gets their notes and tasks done well before sign out, and always, always, always, runs things by the resident when there is any doubt. The resident never wants to be surprised by anything, but also does not need to be updated on every normal hemoglobin that results. It is a fine line finding that balance of when to update or ask the resident for input versus when to push forward and handle that call or blood-draw on your own. Much of this will vary depending on who your senior resident is, and for that reason, it is always a good idea on day one to ask what their expectations are and how they like to run things.  

From the Attending’s perspective: An intern who is prepared, appears engaged, asks intelligent questions, and most importantly, knows their patients backward and forwards. They expect you to be the first to know when a patient’s BMP results, the first to see the patient in the morning as well as being the first to the bedside if they crash. They do not expect you to make complicated medical decisions but instead kick things up to the resident when something doesn’t “feel right.” Most attendings, although not all, will prefer to operate in the “chain of command,” such that the intern will largely report to the resident and it will be the resident who decides if they can make the call or if they need to run it by the attending. It is poor form for the intern to go directly to the attending without looping in the resident (unless of course, there is an issue with the resident themselves). With those perspectives in mind, here are a few practical tips that may serve new interns well as they just start out:

1. TRIAGE and PRIORITIZE

You will be flooded with tasks, some will be the same every day and can be expected (i.e., progress notes, repletion of electrolytes, etc.) and others will crop up throughout the day (pages from nurses, rapid responses, codes, admissions). To avoid getting overloaded, you must have a way of itemizing your tasks such that the emergent ones get done first, the urgent next, leaving the less time-sensitive tasks to the end. What I have found that works well is getting many of the mundane tasks done early in the morning before the unexpected tasks emerge. For example, most interns will elect to come in early, pre-round by looking over charts, vitals, and labs and ordering any electrolytes that may be needed for repletion. From there, they will see the patients and get started on their progress notes. That way, you have cleared much of your “known” To-Do’s before the resident has even come in for the day yet. It is normal and common to have days where your whole list seems to be crashing and the ED is full of admissions waiting for you. It happens and it is OK. That’s when your resident needs to step up and offload your tasks.

2. ORGANIZE YOURSELF

As noted above, the day can become hectic rather quickly, so finding a structure for you to organize yourself is important. Stay consistent once you find what works for you, but also do not be afraid to switch things up if you find it isn’t working for you.

Some common organizational styles are the “folded paper technique.” It is a mix of basic origami and old school list-making. You fold a piece of printer paper enough times to create the number of creased boxes that correspond to the number of patients you are (or will be) carrying. Then in each box, you make little checkboxes of your To-Dos. Often, some will put an acronym at the top like RONMLS standing for Replete (electrolytes), Overnight events, Note, Meds (refill expiring meds), Labs (order for AM), Signout (update), etc. You should find something that works for you.

Many adopt the multicolor pen. You designate different colors for different tasks, which can be helpful. Also, it is nice to designate a particular color to denote things that need to be carried over to the next day. This way when you check your old sheet, you may remind yourself of what needs to be done. Muji pens are a personal favorite (they are reasonably priced, come in many colors, and write smoothly).

I had a colleague who bought a reem of a non-white paper (yellow, blue, pink or otherwise), this way he felt he had less chance of misplacing it (as we all tend to do). And let me tell you, losing your To-Do sheet as an intern feels worse than losing your wallet.

I would also suggest purchasing a small sketchbook (or notebook) that can fit in your white coat pocket. This should serve as a repository of pearls you learn as you make your way through intern year. I also found it great for doodling while in noon-conference or on rounds. It may also serve you well to keep a running list of patients you may want to follow long term and/or for research purposes. If your budget allows, I really like the Moleskine unruled notebooks. Other cheaper options exist that are similar.

3. INTERPERSONAL SKILLS

This will save you. Introduce yourself to the nurses, NPs, PAs, Techs, everyone. Learn their names. Say good morning. Smile. I recognize this sounds like common sense and basic good manners, but I cannot tell you how often this gets overlooked because we are all stressed and overworked. But I can promise you from experience, getting off on the right foot with your support staff will help create a smooth working relationship. I have many anecdotes that prove this, such as the numerous times I could not find a vein for a blood draw and my rapport with the nursing staff was what allowed them to happily step in and help me. It is important to note as well that, especially in July, many of the nurses have more clinical experience than you. It is OK and encouraged to ask a nurse what their thoughts are clinically.

In that same vein, I’d strongly advise against taking the stance of “I am the doctor, I know best and I give the order” mentality. It will not serve you well.

4. YOU CANNOT TAKE GOOD CARE OF YOUR PATIENTS IF YOU DON’T TAKE CARE OF YOURSELF

Sleep when you can. Eat (well) when you can. Caffeinate often. I think it’s a good move to get into a rhythm with your self-care. Create a quiet, dark place for your bedroom (or if you live in a tiny NYC studio, like me, your bed that is in the living room/dining room). Try to limit screen time before bed as it will make it difficult to fall asleep (see; SCN and melatonin). Invest in black-out curtains (great for when on nights). Consider making large healthy dinners and taking the leftovers in for lunch the next day (hospital food is often caloric and carb-heavy). Consider getting two large reusable drink bottles – one for water and one for coffee. Buy an extra phone charger and keep it in your white coat pocket. Always have snacks handy, high protein low carb/low sugar is ideal for energy, such as nuts, fruit, Greek yogurt, etc.

5. ASK FOR HELP

Whether you are unsure about a patient’s clinical status, you cannot seem to get that A-stick, you are dealing with a difficult patient personality, or something more personal is going on: tell someone. Your resident is your ally and will be a good source to turn to first. But keep in mind, you have a lot of other resources around you as well. If it is something quick and patient-related, the nursing staff can be wonderful. If it is more personal, your co-interns, residents, but also chief residents, attendings, and program directors are good resources. Never suffer in silence and always know there are outlets and solutions that exist. Similarly, if you notice your co-intern is struggling, speak. I can promise you that all of us have dark days or even months, but it’s normal – you are not alone.

I hope these tips smooth the rather rocky transition from medical student to intern. You have worked extremely hard for the better part of the last 10 years to get to this place. It will be awkward introducing yourself as “Doctor,” at first, but you earned it and by the end of intern year that awkwardness will fade and your clinical confidence will grow. Deep breath, you got this.

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