shift change handoff

You thought residency was just going to be putting all your immense knowledge into practice? Think again! Well that the majority of the job, and then learning about the next best step, and the next, and the next, etc. etc. However, the idea of “practicing medicine” stems beyond taking a quality history and physical. It becomes about how to best develop rapport with your patients use that in a way to create treatment plans. It includes learning to have goals of care discussions with patients and families, and translating complex medical information into layman’s terms for any to understand. In particular, this post is going to pay close attention to the hand-off, which is one of the most sensitive times of the clinical work day. Depending on your residency, it happens at various times of the day. It means that when you’re leaving for the day, your colleague on call and night float team will need to understand your patients relatively well in order to provide quality care for acute issues.

Let me first address the idea of “acute” issues because as an intern, you are going to want to put out every fire for your team and neatly tuck away their patients for their ease in the morning. While you may be as gung-ho to do so, more often than not, it is about staying afloat in a raft with the Kraken viciously gaining upon you (I just watched Pirates of the Caribbean, so forgive me for the spoiler!). But in all honesty, many issues come up at unusual hours, from families wanting to talk at midnight and the possibility of a specialist consult. The art and craft of medicine comes in managing these calls, both to acknowledge whoever has made it aware to you and address it in a way that does not seem to “why are you calling me about this right now?”. I’ll have a separate post on non-acute issues and examples, but for now, keep this on your radar.

Now, back to my main point about hand off. We have attention spans of a goldfish, and knowing we have to get a sign out for some number of patients, that span is going to shrink, fast. So what you will be able to have to do is come up with the best one liner for patient, and make it clear if they are stable or a “watcher“, aka someone who might give you problems overnight and “WHY“. You should not by listing all their past medical history, just what you think is most relevant to their admission. So their history of left toenail fungus and paper cut in 1990, has got to go! Tell me what they presented with, what you are treating right now, and give me some legitimate what/if scenarios that are particular to this patient (i.e. whether I can diuresis further or not, does this person need BIPAP overnight, etc.). Sign out is a tenuous time for patients, so please do take your time, be thoughtful in your remarks, and ask if your colleague has any questions before leaving. Your written or typed hand off should be free of extra information. I prefer to highlight pertinent tasks to follow up on and what to do with those values too. Again, overnight is not the time to reinvent the wheel, but certainly present new thoughts to your day team, if you feel that will help management. 

Here are some additional thoughts based on a brief search using “hand off internal medicine residency” as my search terms, Sources:
https://jamanetwork.com/journals/jama/fullarticle/2589335
https://www.hopkinsmedicine.org/news/media/releases/reducing_work_hours_for_medical_interns_increases_patient_handoff_risks

the “expert intern”: time management

Probably the two most contradictory words you will hear throughout your experience in your first year in any speciality. My personal opinion is that no matter how hard you try, you will still find yourself struggling to manage your patient load, medical and social, in addition to making it home on time, barring emergent situations with your patients.

A few things I have come to learn in my short stint as an internal medicine resident. The first thing is getting to know whether you are a morning or a night person. If you are a night person, the first thing you will need to learn is…how to become a morning person. It goes without saying because you will need to pre-round on your patients before meeting with your senior resident, and then with your attending. Hospitals vary how they round, and you will also find your niche. For me, I would print off my patient list, write their vitals, review their labs, and then off to the races to interrogate my patients for a few minutes before preparing their progress notes. I went from writing down nearly all of my patient’s review of systems to jotting down their pertinent findings in short form. All the while you will be fielding pages from your nursing teams and other ancillary staff to answer questions and concerns. As the time proven saying goes, “time flies”, and it truly does. So time management is key to understand each of your patient’s history of presenting illness, their medications, allergies, and other relevant history, and how it may or may not contribute to how you treat them during their admission.

We also all took some version of Step 2 CS. We are only allowed 15 minutes in each patient encounter to introduce yourself, perform a full physical examination, and offer your thoughts on their diagnoses and what the next steps are. Knowing you have so many patients to see in the morning, you can also time yourself to ask only the pertinent questions for now. After rounds, I would return to the patient room to update them of the plan, especially discharge planning because that would be a terrible surprise to patients. Prior to our noon conference, I would update each of the nurses about the plans for the day, from medication changes to discharge planning. Unless your program has a nursing rounds, you will need to do this too to ensure everyone is on the same page. No matter the size of your program, floor staff talk, and you do not want to be on anyone’s bad side because they can make or break your experience during rotations. I felt that by doing this, I had a sense of completion that even if I left the floor or did not touch base with the nursing staff from then on, they would know the plan or changes to management. It also sets up a line of communication between you and floor staff so they continue to communicate and advocate on your behalf.

You then should set aside a portion of time to prepare discharge summaries for your patients that likely will be discharged that day or even a day after. You will learn to insert various tasks during brief moments of free time to get ahead of the curve. It is an art that no matter what stage of training you are in, should be an area we consciously focus on. Thats it for now folks, talk to you later. Save a life!

Step 3

Studying and taking step 3 before my intern year was probably the best decision I could have made. I under estimated the learning curve and how tired I would be at the end of the day. I couldn’t imagine sitting down for more hours and studying textbooks/videos. Especially when there is so much to do in a new area! I will say though, being an intern may have helped me a bit for CCS cases, but I don’t think the training I have received so far in my residency would have necessarily increased or decreased my score. I think the majority of preparation should be placed on the CCS cases, if you are taking it before starting any formal training. Otherwise, you’ll get the hang of what labs and tests to order off the bat. Having completed a week of outpatient care, I believe that was beneficial for certain cases too. I can recall several of my family medicine rotation experiences helping me out, more often than out. Step 3 is a great time to recall all those wonderful patient encounters you had as a medical student. For the multiple choice portions though, UWorld was key. It gave me a decent preparation for the types of questions and the length too. Other texts I decided to use were my Step 2 CK notes, and master the boards step 3. I used the latter towards the end of my studying because it was mainly a review book at that point. I did not want to be bogged down in too much detail and wanted just the “what to do” because that is how the exam is going to test you.

There are a few practice exams too that I would highly recommend to any student to take advantage of. My score was the average of the practice exams. It’s seemed to work out for me, so I think the same would apply to other students too. So, don’t be too excited that you got a 250, but get a 200 on another. Use all of these items as study tools for improvement! (but yes, getting a passing score on a practice test is great for morale, lol). Best of luck to anyone taking the exam. Please send questions for new blog posts! Take care.

What are my chances?

A very common question that students and graduates ask across the world. When it comes to selecting applications for interviews, you never really know how the process goes. It could be as simple as picking a file that has a familiar name or undergraduate program or a personal statement that really shined. Then there might be instances where it was entirely luck of the draw and you just so happened to be one of the lucky ones. Each year, programs across the country review thousands of applications for those coveted interview slots. Us applicants are all vying for the same positions, so it’s funny that during interviews we are all so pleasant with one another. Even myself, I recall bonding with other applicants over not having received interviews from several programs and how our experiences had aligned over the interview trail.

Each year, the NRMP publishes their data about the applicant pool for that year. You can also find other nifty little charts and such that companies have published too (see below). However, it is all an average. While many programs do have cut-offs for various board scores, others may be willing to read applications that don’t meet their criteria. At least that was my experience for several programs that apparently explicitly stated they would not interview anyone with less than a 250.

https://www.doctorsintraining.com/blog/usmle-step-1-average-match-scores-by-specialty/

Click to access Charting-Outcomes-US-Allopathic-Seniors-2016.pdf

In my opinion, the best way to increase your chances is to have a stellar application. It should be tidy and well thought out. It shouldn’t be a hodge podge mix of activities that you threw together just because you wanted to fill up the space. Your writing should be thoughtful and really try to express your interest in everything that you have done and accomplished up until now. That is my best advice to increase your chances. Sometimes it is as simple as your grammar and saying the right choice of words. Please keep in touch and happy to help students along the way! Take care.

Residency personal statement editing services

For anyone that is applying for residency in the upcoming cycle, it is not too early to start thinking about your personal statement. You want to be entirely prepared to click “submit” the first day the application opens. The personal statement is so critical these days for more than one reason. Obviously to know that you can express yourself. The other reasons though, are that you are able to discuss the ways you reached your decision to pursue your field. You have to do it concisely because programs will read hundreds of statements! I am offering my services for applicants at a student friendly rate. Feel free to contact me to further discuss. I received 40 interviews for internal medicine, and have a strong history of writing success with students, residents, and fellows. Thanks!