Building Reflexes

So I am now a third of the way into my intern year in my internal medicine residency. The whole enterprise started off as a string of stress and self-doubt inducing thought after another: There is a lot to know and I don't think I'll ever know any of it...Wow, that senior resident is really smart. I'm never going to be that good...Dr. So and So is a great attending, I'm never quite going to get there...I've never done a thoracentesis before. What is I mess up?...What if I kill someone?

Of all of the above, a green intern seeing the sheer confidence and competence of the junior and senior residents was somehow the scariest. It was a mystery how someone could go with my fund of knowledge to their fund of knowledge in a year or two. I was convinced I was the imposter in my intern class, the one for whom the physician production process would fail.

Along these lines, as I've moved through intern year, I've learned three important things. All of these have served to keep me sane in the storm of self-doubt:

1. A scared intern is an intern who has an appropriate level of confidence, and therefore thinks harder and is quicker to ask for help. He/she is therefore a safe intern.
2. Every intern feels the same fear coming into residency.
3. The goals of intern year should be modest. Not, "I want to read everything become a master clinician after 1 month on an inpatient service" but "I want to develop quickly implementable algorithms for common clinical situations that will ensure that I am thorough and efficient."

This last aspect is what I call "reflex building." There is a set of clinical situations that interns and residents will face time and time again. Getting good at working up and troubleshooting those problems builds confidence, saves time and allows you to devote your precious tired brain to more intransigent clinical issues.

I remember my first call night where a gentleman became short of breath. I walked into the patient's room, following a frantic nurse, with a veneer of calm but with the insides of a rookie quarterback facing his first test against a wild, aggressive defense. Thoughts scattered, I correctly asked for a stat chest x-ray, ABG kit, had the angle of the bed increased, and called for stat labs. I listened to the chest and thought it sounded wet, and ordered a diuretic. Prior to all this, I paged the teaching senior resident on call.

It turns out I did alright, but I forgot to get an EKG. In my stressed state, I forgot to think about acute cardiac issues (like heart attacks) as precipitants for this new shortness of breath. Clearly, ruling out heart attacks is an absolute must. Luckily the nurses and the night senior all knew what to do and the EKG machine was in the room and humming before I'd even thought to call out for it. (The patient was not having a heart attack.)

Two months later, I was in the same situation. I walked in to the room, again with some outward swag, but this time with also with an organized work-up plan. I got all the tests I needed to get. It turned out the gentleman had missed his diuretic pill for two days. He sounded "wet" and I diuresed him. His EKG was fine and the patient got better quickly. I then had time to leave and deal with the four new admits that hit the floor all at once, then later check in on this patient before I handed off the service to the day team.

It was at that point I realized that I had actually learned a lot during intern year. At any given point in time, the marginal output of the physician production function is hard to observe. That is, at most points in your training, you are faced with such a huge knowledge base that the distance between you and the ideal always looks limitless – you don’t really feel like you are getting anywhere. However, in situations like the one I just described, or where a patient has new urinary retention, new chest pain, a new GI bleed, we've all now seen enough of these to know how to handle these problems efficiently and safely. It’s a great feeling to have these new clinical reflexes.

Some time later, I took on the roll of "running plans" in our inpatient service. Basically, our inpatient service has four interns that take on different roles every day. The "plan runner" goes through each of the twenty or so patients and decides what needs to be done for that day based on that mornings exam and labs, the previous nights events, and all the accruing data about the clinical course. The junior resident, who runs the team, watches over all of this and chimes in and teaches when necessary (which is a lot, early in the year). The first few times I ran plans I got a lot of much needed and much appreciated input from the junior ("Do you really want to do that? And have you thought about this?"). More recently, I’ve been hearing less from them. And I also have a better sense of the nuances the junior needs to know to run the team effectively - how to discharge patients, when not to get labs, how to deal with a difficult consult service. There was one moment, though brief, where I thought to myself “I think I can do that. I think I can be a good junior.”

That was a small, but important, victory.

Ultimately, perhaps the best lesson from all this is to trust in the production process. As our program director put it during orientation, "[The residency program has] been doing this for years. Sit back, put on your seat belt, and let us do our thing. You'll be fine."