Reflections from Intern Year (Part 1)

I am at the end of my intern year of residency. I completed a year of Internal Medicine, which is required for Neurology residency training. I will then begin my Neurology focused training in a couple of weeks, which will last for 3 years.

First day of Intern Year (Orientation)
June 25, 2020

This past year was arguably one of the most challenging and rewarding times of my life. I knew that internship would be difficult, but I never imagined that my experiences would leave me feeling all of the following: humbled, beaten down, furious, shocked, depressed, exhausted, laughing so hard I was clutching my stomach, overwhelmed, stressed out beyond belief, and ultimately, even more passionate about becoming a competent, empathetic physician for patients.

It has been a whirlwind. A surge of random memories is sweeping over me (many negative I realize haha, but I have more positives to share later): getting cursed out after my 28-hour call by a frustrated patient at the VA who demanded more information about his upcoming orthopedic surgery. Feeling so exhausted after working a non-stop 12-hour overnight shift in the Emergency Department that I found myself walking around the parking garage for a good while because I'd forgotten where I parked (I made it home safely). Getting swung at by an angry patient during my night shift on the Cardiology service because the day team had forgotten to re-order his pain medications. Witnessing the "n" word get thrown around by a drunk, older white woman in the ED. Also in the ED, caring for an acutely psychotic patient who used to lead a drug trafficking ring. In clinic, seeing an Arabic-speaking woman whose agitated son demanded that I prescribe a 3-month supply of narcotics for his opioid-naive mother without any clear indication for them. 

If you haven't already guessed, residency can be quite an entertaining time. The aforementioned experiences taught me the importance of maintaining a calm composure in high-stress situations. The stories certainly don't end there. And they're not all negative either! It has been amazing working with remarkable, selfless co-interns and residents at Duke. I also can't express enough how wonderfully supportive and encouraging the leadership has been (program directors, Chief residents, other faculty). I have been pushed to learn and grow in ways that I truly didn't think were possible. I deeply value the relationships I've been able to build with my patients in both the inpatient and outpatient settings. I am so grateful to one of my senior residents who showered me with affirmation early on in my intern year, generously sharing that I had one of the best bedside manners he had ever seen by any provider. I embraced opportunities to mentor both medical and PA (physician assistant) students, all of whom were valuable additions to the medical team.

I'd like to share a few stories and highlights from my intern year in this entry. For the sake of organization, I will break it up into challenging experiences then I'll end briefly with the rewarding parts of my training thus far. 

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

Intern Year Challenges

Imposter Syndrome: Being at the Bottom of the Trainee Totem Pole

First-year residents (interns) are fledgling physicians who just finished medical school. We are on a steep learning curve throughout the year. Sometimes I found myself wondering: what in the world would I do if I didn't have [insert name of upper level here] around? Fortunately, I gained more confidence and autonomy as the year went on, but I certainly experienced extreme Imposter Syndrome at the beginning. (Photo from here)

First Day of Intern Year                       

I'll never forget my very first day of intern year: I started off on the Stroke service (Internal Medicine residents at Duke complete a few weeks of Neurology every year during their training). Looking back, it's embarrassing to think about how little I knew at the time. I never got paged as a medical student, so when my pager went off for the first time, I didn't even realize that it was mine. 

As a medical student, no one will yell at you for accidentally leaving your pager at home, or for forgetting your stethoscope or other examination supplies one day. As a resident, you wouldn't dare leave anything behind. In the mornings before driving to the hospital, I got into the habit of double-checking to make sure that I had my hospital ID, pager, stethoscope, face shield (when it was still mandated we wear them), alcohol wipes (to clean my stethoscope), and most importantly, my phone, which is always a lifeline at work. 

Anyway, my JAR (junior assistant resident; second-year resident) had to tell me that it was my pager going off. When I silenced it, I didn't even know how to work it to read the entire message. I internally scolded myself for not fiddling with it ahead of time to figure out how to properly navigate its functioning. The page was about my patient who now had low blood pressure and was feeling symptomatic (lightheaded). His other vitals were fine. I stared at the page. It suddenly felt like all knowledge I may have had about hypotension washed out of my brain. I also didn't know this patient very well as it was my first day on the service. I was finally able to move my feet to find the nearest phone to call the nurse back and ask for more information. She sounded so calm. I was so nervous. 

"Hey Dr. Rose, Mr. E's blood pressure is 86/49 after checking it three times. He says he's feeling a little lightheaded but is otherwise stable. His other vitals look fine. Do you want to give him fluids?"

I froze. Wow, she just called me Dr. Rose. That's me. I pinched myself to re-focus. I had to make a decision. But I wasn't sure what to do! I turned around to see that our team was still rounding. The attending was teaching about common stroke etiologies and the medical students, nurse practitioner, and JAR were listening intently. Crap, I didn't want to pull my upper level away to ask for her help with something this simple. I wracked my brain for what to do next. The nurse, sensing my hesitancy through my silence, offered, "We can give him fluids. They gave some when this happened before. How much do you want to give?" 

I wanted to kick myself. I didn't even know what to tell her for how much or what kind of fluid to give.  "Um... how much fluid did he get before?" I finally got some words out. 

"One liter of normal saline," she replied.

"Okay, let's do that," I told her, happy to have resolved this so I could return to rounds with the rest of the group.

"Sounds good. Would you mind putting in an order for the fluid?"

I froze again. I didn't know how to put in that order! Darn, I didn't know how to do anything. I felt so incompetent. Fortunately, my upper level had by now broken away from the team to see if I needed help. She saved me by showing me how to put in the order. The patient remained stable and his blood pressure improved slightly with the fluid bolus, but later that afternoon we explored and aimed to address the reasons why his blood pressure was intermittently dropping.

Now, one year later, I know exactly how I'd approach this situation differently. After getting the page, I'd call the nurse back while reading through the patient's chart to get information more quickly. I would ask for the other vital signs. If they're unremarkable, I'd clarify where and how exactly the blood pressure was measured. Sometimes the read is inaccurate because the blood pressure cuff is not tightened properly or it's placed on the patient's forearm or leg (yes, this has happened before). I would then, in no particular order, and while reviewing information in the chart, inquire about where the patient's blood pressure usually runs (i.e. is the 86/49 reading just slightly lower than a baseline of 90s/50s?), if he was mentating well or experiencing any other symptoms, if there were any concerns about an infection, if he had a history of heart failure, advanced renal disease, or cirrhosis (to determine how much fluid to give him), etc. The nurse would probably be able to answer most if not all of these questions. I would then fill in the gaps with my chart review. It's important to gather and synthesize information quickly to determine the next steps.

If there was any indication that the patient was acutely unstable, such as other concerning vital signs (i.e. needing oxygen to breathe, very fast heart rate) or looking unwell (i.e. pale, perhaps frank bleeding from a clear source such as the rectum), I would not waste time reviewing his chart. I would immediately go to the bedside to evaluate and stabilize the patient. 

I hope to grow in these other important areas as I continue on in my training: 

• Pathophysiologies: My co-interns and I worked our butts off in medical school to solidify our understanding of numerous pathophysiologies that underlie disease processes. As an intern, though my many patient encounters helped hone my knowledge base, I still felt much of this mastery slip away because I wasn't using certain concepts. Lord knows much of the minuscule basic science details we needed to master for Step 1 have dissipated from many residents' minds. I remember more from my Step 2 studying, and perhaps even more from Step 3, but the knowledge I am not using or cases I'm not seeing often (i.e. biostatistics concepts, management of certain cardiologic emergencies such as pericardial tamponade, specific infectious diseases, etc) has inevitably faded. Fortunately, this knowledge is revived and sharpened with more experience and patient encounters.

• RRTs/Codes: (RRT = Rapid Response Team; a patient is unstable, Code = code blue; a patient's heart stops). Throughout the year, I was involved in multiple RRTs and a handful of codes in the inpatient setting, but I led few. I aspire to emulate my senior residents who are confident leaders in emergent situations such as these in the hospital. It takes tremendous skill to calmly, efficiently, and effectively lead a team of clinicians (nurses, respiratory therapists, pharmacists, etc) to achieve optimal quality of care for an unstable patient.

• Goals of Care discussions: Leading conversations with families and patients with terminal illnesses about life-sustaining interventions is such an important skill to hone as a provider. My uneasiness with goals of care discussions stems from a traumatizing experience on the general medicine service: I cared for a patient with terminal bladder cancer who we planned to discharge to home hospice per his wishes. However, the day prior to discharge, he developed major clotting in this bladder that we presumed eroded into a nearby artery, causing massive bleeding. This was completely unexpected. My attending swiftly and gently led a discussion with the daughter about the possibility that the patient could pass away that evening. 

Unfortunately, he died sooner than that evening. After our conversation with the daughter, the attending and I exited the room to place comfort care orders, but not too long after those orders were signed did we hear the daughter scream. A nurse came rushing over to the work station. She tapped me forcefully on the shoulder then waved me over. "We need a doctor, we need a doctor!" She then rushed back into the patient's room. The attending and I were on her heels.

When we entered the room, the daughter was still screaming. Her knees buckled, her head bowed and grazing her father's face, her hands tightly gripping the head of the bed. "Please know that I did all I could!" she cried. The patient looked very pale; he was staring into the distance with lifeless eyes. The nurse looked at me and the attending and shook her head gently before averting our gaze, as if to say, "He's gone."

Another nurse grabbed hold of the daughter before she lost her balance. She was then led out of the room. That was the first time that I pronounced a patient dead. I heard the daughter's screams in my sleep that night. I remember waking up in a panic to those screams, distressed and heartbroken.  

Moving forward, I know that I will lead more goals of care conversations with patients and their families. It is important to be able to do so with deep empathy, candor, and compassion.