Monday, June 20, 2011

Hints for New Residents

I was a general surgery residency program director for 24 years. I’ve seen them come and go. Here is some advice for those of you who are beginning residency training.

Never be afraid to say "I don't know."

Never be afraid to ask for help. Some of the worst disasters I have ever seen were because a resident didn't want to bother a more senior resident or an attending and blundered badly.

Respect your colleagues and your patients.

Until you gain a great deal of confidence, do not manage things over the telephone.

A patient who is restless or anxious may be hypoxic. Make liberal use of the pulse oximeter. Do not sedate a restless patient without personally seeing him.

Sometimes postoperative abdominal pain is due to urinary bladder distension. Learn how to use the bladder scanner yourself. 50 mL of urine output could be overflow incontinence.

Trust, but verify. [Or better yet, at first trust no one.] For example if someone tells you a lab result, say thanks and look at all the lab results in the computer yourself. Many times the nurse will say, “The labs are normal” and later you will find that the serum CO2 was 15.

Listen to the nurses (if they seem to know their stuff). They can really help you if you let them.

Be good to the nurses. If you are a jerk, they can make your life miserable.

If a nurse you trust calls and says a patient “doesn’t look good,” get to the floor as fast as you can.

You will get busy. Learn to prioritize. Learn what can wait and what needs to be done immediately.

Look at all your patients’ imaging studies yourself. Don’t just rely on reports. One, you will learn how to read them. Two, radiologists are not infallible. One of my PAs recently picked up abdominal free air that was missed by a radiologist. When in doubt, review the studies with a radiologist in person. I do it all the time.

Read, read, read. This isn't like school. You can't cram for your boards. You can’t learn 4 or 5 years’ worth of material in a one-week review course. You have to learn it as you go along.

Don’t embarrass your peers on attending rounds or at a conference. If you are asked a question and you know the answer fine. But if your chief resident is presenting a case to the chairman and says the patient’s hemoglobin was 7.2 gm/dL, don’t raise your hand and say, "Oh, no. it was 7.6.”

In the “Information Age,” there is no excuse for not obtaining old records on a patient. I have had op notes and path reports faxed from Ecuador. Surely you can get them from the hospital across town.

Can you think of more tips? I am open to all suggestions.


Jeremiah said...

While I am still years away from needing this info I still appreciate you putting it out there.

Thank you.

NB said...

This is great information. Thank you.

Dermot O'Riordan said...

There are only three rules: ask, ask & ask. If you don't ask you're on your own.

By end of post should aim firstly to spot the sick patient from end of the bed (a skill you probably had BEFORE entering medical school but now can only link in terms of numbers, oxygen sat, UO, reps rate etc.

Secondly learn how to prioritise and organise your time

Skeptical Scalpel said...

Dermot, good comments. I would add "listen" as well. Listen to your patients. They will often tell you what is wrong.

KSibert said...

A great list--just as appropriate for residents in any field, not exclusive to surgery. Other small points: Don't look at your phone during rounds. Don't look at your phone during conferences. And please don't regard Wikipedia as a reliable source for medical information.

Skeptical Scalpel said...


Thanks for the pertinent comments. Ah, yes. Wikipedia. A few more and maybe we'll have enough for a handbook.

Anonymous said...

Always address to paints by name, not by room number or disease

I'd stress again the reminder of not studying from Wikipedi

Anonymous said...

"Don’t embarrass your peers on attending rounds or at a conference. If you are asked a question and you know the answer fine. But if your chief resident is presenting a case to the chairman and says the patient’s hemoglobin was 7.2 gm/dL, don’t raise your hand and say, "Oh, no. it was 7.6.”"


I have to tell you that as a patient, I find this recommendation very disturbing. My safety and the exchange of *accurate* information about my health are FAR more important to me than one intern protecting another from simple embarrassment that does not threaten their actual health and safety. Since this suggestion is here, I'm sure it is probably happening on a regular basis. This does not inspire confidence.

Skeptical Scalpel said...

Here is a comment from a Reader named Hank. I did not post the entire text because it contained an insult, which I do not permit.

"Get off of your high horse. They are referring to embarrassing one another in a teaching setting to gain favor from bosses. The correct information is available to everyone, it's not just hiding in one person's brain. The author chose an esoteric example. People like you make practicing medicine so painful."

Hank is correct. I was referring to a teaching, not a patient care, situation. Things like lab tests are available for all to see. Also, the difference between a hematocrit of 7.2 and 7.6 is not really a clinically significant one.

Anonymous said...

Have to agree with anonymous. I mean it was a simple mistake, there should not be that much of a flip out on someone missing a number.

When there is, what you are reinforcing is teaching people that a doctors' ego and personal is more than a patient.

Skeptical Scalpel said...

Anon from last night, I do not understand what you mean. This was about teaching rounds. You and the other anon don't get it.

Anonymous said...

I would like to add a little, even though it is a little repetitive:

1) Swallow your ego, a lot of MS's today have gone through multiple interviews and with the new stress on character in med schools you generally find good people. This has nothing to do with your ego academically. A lot of us have had variety of academic achievements and that is wonderful, but now you are taking care of people and this is a whole new ball game. Leave your past success behind and know its okay to be wrong, to not know everything, and that as stated above have to ask a lot of questions.

2) Every program has a different culture. The surgical program in my home school had such a cohesive atmosphere. Residents and attendings all trying to help each other out and working as a team. Where I am at as a resident, unfortunately, has a competitive atmosphere, less team work. For ex, if I am studying for absite I might go over some practice questions with a colleague. This is part of team building, working together. The program where I am at attendings even compete with each other and this negativity has been passed down to residents. I do think the chief residents and upper yrs set a culture. As a result, what I have done is become a leader, organized a lot, discussed a lot of the weaknesses and illustrated how an unhealthy competitive atmosphere is not going to make us better docs/surgeons. Be bold, discuss things with your co-residents, after all its 5 yrs or more with them if you are in a surg res.

3) There will be dark days, you will get chewed out and embarrassed by an attending. Learn from your mistakes. Do NOT take it so personally. There might be an event when something was not your fault or there was a misunderstanding, you still get yelled at. This is medicine, the level of stress is high, know that there will be moments like this. Be strong in how you handle things, be professional, listen, discuss it out. If someone is so angry that you cannot have a discussion, seek advice from a higher up, but do not make it into a big ordeal.

4) Offer to help out when appropriate, know when to say NO, and do not allow anyone to take advantage of you because you will be with this program for a few yrs.

** I have to agree with Skeptical Scalpel, patient care is always a priority. Skep Scal used an example with labs and I see why anon did not understand. He was simply illustrating how doctors in training can embarrass each other purposely to look better. Trust me there are multiple people looking over labs, they would speak up. He was just using an random ex to discuss how embarrassing your colleagues for a gain is not right during rounds. His example had nothing to do with quality of care.

I'll add more if I think of something, thank you.

Skeptical Scalpel said...

Anon, good points. Thanks for backing me up on the issue of residents trying to one up each other.

Liz Ditz said...

I am a patient, not a resident or any other kind of medical professional.

Treat your patients as YOU would wish to be treated, no matter how old, ill-smelling, demented, aggressive, or otherwise off-putting to you they may be.

I know it is hard to remember such in the middle of the night with a difficult patient. But rededicate yourself to that goal at the start of every shift.

Skeptical Scalpel said...

Liz, thank you for your input. Good advice.

Debra Gottsleben said...

Love Liz's comments. Will add as a patient to always listen to your patients. If they say something is bothering them listen. If something concerns them don't trivialize it.
Skep your advice despite being 7 yrs old seems just as relevant today.

Skeptical Scalpel said...

Debra, thanks.

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