10 Unwritten Rules of Internship

Not everything you need to know to succeed as a medical intern will be written down somewhere.
(Yes, I know this would have been better to post in July than in September...)
#internship #interncrashcourse

[@London1869]

# 11) Touch base with your patient's assigned RN. The RN has patient and hospital info that you do not know.

[@StrongMed]

Argh! I can't believe I left this off. This is second only to not lying in importance among the unwritten rules of internship. (Although I hope most intern orientations explicitly include this)

[@mleto3459]

BRAVO. Many a med student and intern have felt the wrath of crossing a floor nurse.

[@eduardomacedo7126]

One day I asked for a chair for a patient, but it was one from the nurses. As he noticed that I was totally scared and saw that the chair was for the patient, he looked at me dead in the eye and said: NO. And then told me he was joking. We laughed together. I left shaking, but with the chair.

[@ConanLiuMD]

Love the comment about sending medical students home as soon as their responsibilities and opportunities for learning are done for the day. I always remember as a med student wondering how residents so quickly forgot the experience of medical school and sitting in the corner twiddling your thumbs like you said. At the very least I try to let the students know it is okay to be studying or doing UWorld if we are waiting for an admission because I remember how much studying there is as a MS3 for shelf exams even after you leave the hospital, and I generally try to get my students home by 4pm or so on average. Just don’t be the resident who “forgot” that the med student was there haha! Also as an intern sometimes you will feel uncomfortable sending them home without asking your senior but you can always mediate things by gently probing your senior “hey do we still need the med student anymore” and help expedite them getting home at a reasonable time!

[@sunshinesmile94]

LOL, I think if as a medical student you are easily "forgotten" and "sitting in a corner twiddling your thumbs"... Then you are not being proactive enough. Back when I was a medical student, I would come in for early morning ward rounds and on the occasion that the team was on take that day, I would often would stay late into the night (10pm) when the surgical trainee was on call. Whenever I was around I endeavoured to be of assistance and expedite the consultation for the resident by locating the medical case notes, observation/drug charts, pathology forms and equipment, getting gloves in their size, pulling around the patient bed curtains, writing in case notes as they dictated (they would check and sign)... It may not sound like much but it definitely adds up. In return I got sooooo much fantastic hands on teaching. I became good friends with the residents, they told me what was good and bad about their respective surgical fields, they taught me minor procedures (cannula insertions, chest drain insertions etc). They also invited me to scrub in on surgeries. When you are a medical student, scrubbing in means having an unobstructed view of the surgery (rather than be on tip toes peering over shoulders or trying not to fall asleep in a corner because you can't see...). Therefore you definitely do not mind assisting, acting as a human retractor and an extra pair of hands. I also got the opportunity to actively participate in surgeries: below knee amputation, manning the camera in many laparoscopic cholecystectomies and appendicectomy cases, practice suturing close laparotomy incisions etc. Residents are busy people and they are not obliged to teach medical students. As a medical student your goal is not just to not get in the way and ask questions... But also to be keen and helpful. Sure... As a medical student you can always go home by 4pm... But don't be surprised if your hospital experience does consist of a lot of thumb twiddling.

[@ConanLiuMD]

@@sunshinesmile94 it’s a balance. You need to be proactive but it is also the duty of residents to teach medical students and to send them home on time. It’s not feasible for medical students these days to be coming in at 5am for prerounding and leaving at 10pm - not only is that detrimental to their wellbeing and ability to study for shelves which has a huge impact on their careers and options for residency, but also it’s almost a toxic standard to hold our medical students to. It’s possible that nowadays is simply a different era than when you were training though! But I agree with your point about needing to be proactive.

[@sunshinesmile94]

Conan Liu, M.D. My era was just over a decade ago... Not dinosaur years by most accounts, however your opinion may differ. So many students these days turn up with a sense of entitlement to be taught. I'm here... So teach me. There is a great deal of passivity. What they do not realise is that residents teach medical students when they have the time but it is not their primary duty nor are they being paid to do so... Their priority first and foremost is the care of patients. A medical student who is not proactive will get a decent amount of teaching if the resident is nice and not too busy... And the absolute bare minimum (to the point where they are "forgotten" and "twiddling their thumbs") if the resident is busy and the medical student is not proactive. Many of my medical student colleagues at the time went home at 4pm. Some even pretended to have "lectures" at the medical school so they could skip out early. They are then surprised when I have been able to network and have connections with consultants and residents from a wide array of surgical specialities, extra teaching and learning experiences and regularly scrub in. You get what you put into it. You don't have to preround at 5am stay until 10pm every night. No one expects that. But at least once or twice a week makes a big impression for a 4-6 week surgical rotation.

[@kaitlynkilpatrick36]

In my hospital the culture default is hands off with medical students for the most part so it is very frustrating that I have to fight for my hands on experiences. Most are very content just letting me sit in a corner and I have to constantly ask to do stuff because if they aren't gonna loop me in I'd rather be at home. I will say that this approach of pushing myself to the front of the line does help impress attendings and the few residents that care though.

[@MikeBirkhead]

Dr. Strong, you've been amazing. After completing 2-years of residency, I didn't realize it was an unstated rule to not take the clerks chair. Luckily, I can only recall doing that once... and without any consequences, to my recollection. I'd like to add a few things that may seem like "no brainers" to some, but not at all obvious to others: 1). Never post anything about your work, work conditions, or otherwise on Social media. Even if you follow privacy rules, and de-identify all information, do not post stories about patient's without asking their permission, and discussing with a senior resident or attending. And NEVER use your social platform to complain about an interaction with nursing, house faculty, attending, patient, etc. 2). Related: If you have something bothering you, and you need to put verbalize it, to get it off of your chest, best to write it in a diary or journal first. See if that provides relief. If not, discuss with a confidant. If you have nobody available, utilize an therapist, even if it's telehealth such as BetterHelp, TalkSpace, or something similar.

[@sunshinesmile94]

Here are a few more Rule #11: If you are calling for a consult, have the observation chart, patient notes and relevant blood results in front of you... Don't make the person on the line wait while you log onto the computer and fumble around in the notes in order to tell them the potassium, sodium or CRP levels and other relevant info. Rule #12: When calling for a consult, rather than meandering, be upfront within the first sentence about what the topic is about and what you need. E.g. Problem/patient symptom and whether you just need phone advice vs in person consult and how urgently. Get to the point from the start. Don't make the person taking the consult listen to the entire meandering story before finding out at the end what you want from them. This is especially the case for surgical consults. Rule #13: Don't go running off to the operating room to butter up to the seniors and show your keen interest, if you have not completed your patient tasks on the ward first. As an intern your primary duty is to take care of the ward patients. Getting extra surgical exposure is a bonus, not a priority. Your colleagues on the ward will not appreciate taking up the slack because you have disappeared to the operation room and word will get around... Rule #14: If you are inundated with calls because your pager keeps going off, try to triage them and give the nurses an idea of approximately when you might get there. They understand you are busy also, so by giving them an idea of the timeframe, they are less likely to double page you again Rule #15: Never, I repeat, NEVER EVER tick off the nurses. They can be your biggest allies and often have an absolute wealth of experience... And are especially helpful for newbie interns. However every year there is a foolish cocky intern who disrespects the nurses... And then they wonder why their pagers are going off constantly and why they can't catch a break. BE RESPECTFUL.

[@HilmyA.S.]

Can you please elaborate on how to "triage the pages?"

[@Lena-fg4vj]

Thank you. They don't teach this in school, and yet not knowing this can get you off to a really bad start, no matter how brilliant you are academically.

[@brantleybond2042]

Just started a Sub I this week and this is very valuable. I also got sent home early from my resident after my notes were done, which was very nice indeed.

[@AnnieChaster]

1) 1:23 Don't sit in the chair reserved for the clerk or charge nurse. 2) 1:49 Be proactive in letting your medical student go home at the end of the day. 3) 2:23 Use your pharmacists. 4) 3:23 If you take from the common food supply, you needto periodically contribute to the common food supply (excluding food that is provided by the hospital or residency program). 5) 3:37 Do not speak disrespectfully of patients, ever. 6) 4:13 When chairs are limited, they go to the most senior people in the room (unless otherwise needed for medical reasons). But if an attending offers you their chair, just politely thank them and sit down. 7) 4:45 Let your attending know if you are being mistreated in the hospital or clinic. 8) 6:18 Regarding "bounce back" decisions, take ownership of your patients and do what makes sense for patient care, rather then being dogmatic about the rules. 9) 7:48 Call consults early in the day. 10) 8:15 Never lie.

[@sunving]

Thank you Dr Strong. Thanks God I survived that , every now and then still have PTSD about that. After listen to your many lectures occasionally get a late mid life crisis want to be a PGY I again the correct mistake. But afraid I might not survive :).

[@folumb]

Great rules, even applies to general surgery if you redefine bounce-back for us to be from one specialty service to another (patient on HPB who develops a hernia less than 1 month after a liver surgery can usually still be taken care of by HPB, doesn't dogmatically have to go to general surgery service unless HPB attending seriously can't fix a hernia any more).

[@Andinov02]

Great stuff. Love your videos strong-med. Here are my 4 that I say to any intern who's worried about what to study etc before their first day. Turn up on time. (be reliable) Work hard. (be professional) Keep you attendings informed. (be self aware) Keep the nurses sweet. (be cordial)

[@ConanLiuMD]

A popular saying I heard once which is pretty similar to your advice: good interns are ones who are available, affable, and able! I think the biggest one is being affable. Having a positive attitude is so important

[@omercagatayduman3924]

Stand up for your clinical decisions if you are sure about them however be super careful about disrespecting your seniors while doing so. There are no better way to gain confidence of your seniors than standing up for yourself.

[@ldam]

Want a bonus point: talk to your RN when you write an order. Communication is extremely important. So if you want it done, talk to your RN. RN will appreciate you for communicating with them. But if you write an order and don’t tell the RN, it could be hours before they see the order on the computer. I can tell you it drive nurses crazy when you write a big work up and not tell them about

[@EdieofOdessa-nr1tl]

Double bonus: Never refer to the patient's RN as "your RN" (or think of an RN as "your RN") and you will be more likely to internalize you are a member of a patient care team rather than the center of it.

[@user-sd4hi8yp9t]

Thank you for that! I’m two weeks into internship and all the things you mentioned are really helpful. I would also add that senior residents, nurses etc are human too and they would like to talk about other things than medicine sometimes. Don’t forget that, it helps bond with the team better :)

[@fun-fx3wg]

Bro How much is ur monthly internship salary? We don't have any money in our hospital😭

[@MJLai85]

Here’s a good tip: if you don’t like being wrong, then being an intern is not for you,

[@jennismith2]

I’m an ICU nurse…here is WHY it’s not ok to walk up and start using a computer or chair without asking.: YOU can walk away and use ANY chair or workstation you like. But the person whose computer you’re “poaching” can’t. For security reasons, the desk clerk can’t leave the front desk unsupervised. The Charge Nurse has to be at THAT computer because everyone on the unit knows that that’s where he or she can be found in an emergency. And an ICU nurse can’t leave his or her patient unattended…if the nurse steps away (even for a moment) he or she has to ask another nurse to watch the patient. So the ICU nurse NEEDS to use that computer near the pt’s room in order to maintain “line of sight” on the patient and the monitors. But you don’t. And if you do then you’ll unknowingly be inconveniencing others. So please, if you want to avoid inadvertently making someone else’s day harder, just ask before using a computer in a patient care area. If you do, you’ll quickly earn a reputation as being both a “team player” and someone who is aware of both your surroundings and your impact on those around you!

[@cornelbacauanu1544]

Agreed 100%.

[@jonnyunited]

As a nurse, that first one made me laugh!

[@twistedtea7046]

our hospital system has its problems but at least its never lack of computers.... except for the ED at one hospital where they have 8 computers locked for clerk use only (but no-one is ever on them), and we can't log into any computer in ED.... fortunately its epic so I just use my phone for most things anyway

[@abdiqaws9136]

Thank you very much

[@JohnnyWishbone85]

5:08 -- I'm a rising med student, but I've been an EMT for several years, so I'm no stranger to doctors and nurses telling me what a screwup I am. 😁 It's all part of the job. Nobody can keep it a hundred percent together, a hundred percent of the time, and this field is stressful enough even *without* a bimodal plague.

[@Alphacentauri819]

Be careful with the narrative! As an RN, I never told someone what a screwup they were... when we personalize and confuse our identity (I am) with a correction, we misconstrue much. Our mental constructs, cognitive distortions can derail us. If you think from the angle of patient safety is #1, you’ll never label it as someone telling you you’re a screwup again. Yes, there are arrogant and insensitive people...but that realm is from their ego & issues. It’s good that you do see we are all human and no one gets it right 100%. With that backdrop maybe you can drop the “screwup” label permanently and embrace the human label.

[@JohnnyWishbone85]

@@Alphacentauri819 - You sound like a kind and thoughtful person, and that's a wonderful thing. The classic weakness of kind and thoughtful people, though, is that although they usually realize that others can be unkind and thoughtless, they frequently cannot conceive of the degree to which other people can be truly horrible. So yeah. You may never have tried to be mean. But others have. And believe me, I'm mature enough to know the difference. It is ironic that medicine is one of the more toxic fields.

[@Alphacentauri819]

@@JohnnyWishbone85 I’ve had doctors and surgeons be terrible to me...and some wonderful. I’m now a grandparent...and have done a lot of healing. I don’t let others treatment of me define me. That’s what I’m hoping for, for you 💛💫

[@Alphacentauri819]

@@JohnnyWishbone85 my kindness and thoughtfulness is through much personal tragedy and hardship. More than the average person. My kindness and thoughtfulness is far from a weakness...I’m sure I’ve been “mean” in my life, although I try not to be. I just don’t want to become that which I don’t like...

[@JohnnyWishbone85]

@@Alphacentauri819 - Easier said than done, but that's a different topic, and I appreciate the words of wisdom in any case.

[@Luiz-ww9yt]

Hi Dr. Strong. First of all, thank you for your channel e sorry for my english (i'm brazilian). Do you recommend any book with multiple choice questions that I can use to improve my clinical skills? Thanks in advance.

[@StrongMed]

Unfortunately, not really. For internal medicine residents, the closest thing there is to a gold standard for test prep is MKSAP (to prepare for the IM board exam), but it is too detailed/advanced for most other situations, and I believe a print version of the question book is only available if purchased as part of a $600+ bundle with their complete text prep series. And even then, it's not really aimed at "clinical skills" in their entirety per se, but rather a combination of medical knowledge and basic clinical reasoning skills. (I think of "clinical skills" as also including interview and exam skills - which MKSAP doesn't cover.)

[@Pakanahymni]

Studying and practicing medicine in the US seems like eternal hell.

[@HilmyA.S.]

They earn many times more than doctors from other parts of the world (especially if you compare it to asia) So..... Maybe it's worth it

[@user-yj6nb2xl3g]

Cool♥️❤️☕🤝

[@kungfuseadog]

When you discuss something with one resident, don't discuss it with another. Views in medicine differ often and for many reasons and you're setting yourself up for making one of them feel disrespected. You gotta be a boss whiiiisperer.

[@makS-tm2xo]

Discovering hidden pitfalls of the others is not appropriate

[@makS-tm2xo]

May not be appropriate to be post

[@StrongMed]

Why not?

[@Alphacentauri819]

How in the world is this not appropriate? This is absolutely appropriate and relevant. Maybe you have some narratives that need addressing?

[@edvardso]

you're making a video about not sitting in someones chair because someone will get mad? look at yourself, this is embarrassing

[@StrongMed]

Look in the comments here and you will see that this is a non-negligible issue from the nurses' and clerks' perspectives, which means it's a non-negligible issue from the interns' perspective. I said at the beginning of the video that many of the "unwritten rules" of being an intern are about how healthcare professionals interact with one another in the clinical setting. That includes how to show each other respect, and includes an awareness of how one's actions impact the workflow of their colleagues.

[@edvardso]

@@StrongMed i understand the problem with using the computer. but... it's a chair. no matter what perspective you try to look at it from, it is still a chair.

[@StrongMed]

It's not a matter of the physical piece of furniture (the chairs are usually all the same at the nursing stations anyway), but it's rather the workspace to which the chair belongs. So by sitting in the "wrong" chair, the intern is occupying someone else's workspace.

[@alvaro37nf]

@@StrongMed Dr Strong you are right! Your advice is so valuable, do not pay attention to these comments

[@sunshinesmile94]

@edvard It is not the physical chair itself... You can swap the chairs around because they are usually all the same at the ward general workstation. It is the physical occupation of the "seat" and particular workstation of the ward clerk. Unlike the ward nurses and doctors who constantly move in and out of the workstation area, the ward clerk is singularly stationed at their desk (unless on a bathroom or meal break) and are in charge of receiving the vast majority of main general incoming and outgoing calls directed to that ward (from patients, from relatives, from other departments e.g. Radiology, operating theatres, emergency department, oncology etc requesting patient transfer in or out). So you do not take their seat without permission first (I.e. If All the other computers and phones are in use, you need to quickly use it urgently and the ward clerk is currently not occupied). It's about showing courtesy and some insight into the roles and dynamics of the various individuals within the team. The same rule applies in the ICU, where there is one computer and seat to each room, attended to by a single nurse. In this case, the nurse is responsible for the care of that single patient and are not free to move about. So prior to taking their "seat" and using their computer, it is a simple matter of professional courtesy to first ask. They will be more than happy to oblige. So please go sit yourself and your "woke" sentiments down... On any chair you so prefer, since it is highly unlikely based on your response that you will ever get to the position where sitting in the hospital clerk's seat as an intern will ever be an issue... and stop embarrassing yourself commenting on something you clearly do not understand.