Resident Readiness General Surgery (4 page)

This is the fun of medicine. Patients are people with wonderful stories. A patient with lung or pancreatic cancer who has a daughter about to graduate from law school will likely respond very differently to “standard therapy” compared with a Norwegian bachelor farmer whose immediate future is completely encompassed by the snowy winter of his discontent. Clinical medicine is not like physics, where when you drop a brick out of the window, you expect it to go down every time. In medicine it is frankly surprising when 2 patients with an identical diagnosis respond to “conventional therapy” in the same manner.

Patients’ symptoms are their perceptions, and perceptions are more important than reality. You have a role in helping to shape their perceptions, especially if you work to understand and care about what they think. Patients want to trust and love you. This trust in surgical therapy is a formidable tool. The more a
patient understands about his or her disease, the more the patient can participate in getting better. Recovery is faster when the patient helps.

Similarly, the more the patient understands about his or her therapy (including its side effects and potential complications), the more effective that therapy is (this principle is not in the textbooks). You can be your patients’ interpreter as they work to understand what is going on. This is the fun of surgery—and medicine.

SIMPLE RULES FROM THE TRENCHES

Some of your job as an intern is only indirectly related to patient care. While the rules below don’t tell you how to operate better, they will help you to be a more effective team member and colleague. These elements are important for any medical specialty, but especially in surgery where the stakes are that much higher.

Get along with the nurses.
The nurses know more than you do about the codes, routines, and rituals of making the wards run smoothly. In the beginning they often know more than you do about how to treat the most commonly encountered problems. They may not know as much about pheochromocytomas and intermediate filaments, but about the stuff that matters, they know a lot. Acknowledge that, ask politely, and they will take you under their wings and teach you a ton.

Stay in the loop.
In the beginning, you may not feel like a real part of the team. If you are persistent and reliable, however, soon your residents will trust you with more important jobs.

Talk to your patients.
Chatting with the patient is one of the places where you can soar to the top of the team. As an intern, you have the opportunity to place the patient’s chief complaint into the context of the rest of his or her life. Talk to your patients about everything (including their disease and therapy) and they will love you for it. You can serve a real purpose as a listener and translator for the patient and his or her family. While it isn’t appropriate to do this in the middle of morning rounds, you can often have these conversations in the afternoon as you check on your patients.

Say “Thank you.”
When you are lost (and you will be), the most effective answer to many questions includes a “Thank you.” Like enthusiasm, gratitude is an invaluable tool on the wards.

Say “Thank you,” revisited.
Thank you can also be used to avoid making a bad situation worse. In general, most clinical questions can be answered with a “yes,” “no,” “I don’t know,” or “thank you.” The “thank you” is for those times when all the other answers seem wrong. This takes practice and can initially feel awkward. For example, let’s say you were told to do something by your senior resident but were later called by the attending who was not happy with this action. She asks, “Is that what you always do
in this situation?” There are no good answers to this question, only answers that are less bad. If you say no, then you are going to ultimately get cornered and end up having to throw your senior resident under the bus (always a terrible idea). If you answer yes, you are needlessly sabotaging yourself. The best option is to simply say, “Thank you for the feedback, I’ll make sure it doesn’t happen again.” This usually works to diffuse the situation, and demonstrates humility, an interest in learning, and concern for the patient.

Be punctual.
Type A people don’t like to wait, and most surgeons are nothing if not type A.

Be clean.
You must look, act, and smell like a doctor. You owe at least that much to your patients and your colleagues.

TIME MANAGEMENT AND EFFICIENCY

It is the rare intern who is intuitively efficient. For most of us it involves reflection and practice. The most important thing you can do to be more efficient is to be constantly analyzing your behavior, looking for opportunities to shave off a second here or a minute there. If you do that enough times, those seconds and minutes accumulate and pretty soon you are “in the flow,” where you make it look easy to handle everything that comes your way.

Of course, there are some helpful tips that you don’t need to reinvent:

Notes should be succinct.
Most surgeons move their lips when they read—so keep it short and to the point.

If you aren’t busy, you are wasting time.
There is always something that can be done, and if you aren’t busy, you aren’t thinking far enough ahead. Pro-actively anticipating future tasks will help smooth the workload.

Understand the difference between urgent and important.
While many tasks are urgent, not all of them are important. The difference is easy to see when, for example, you get a page to renew an order for restraints while you are having a conversation with the attending about the course of a sick patient. But there are many other times when deciding which task to do first will be more difficult. Try and step back and assess what things are truly important, and prioritize them.

Write it down.
You might have heard the saying “there are two kinds of interns—those who write it down and those who forget.” Writing things down and periodically reviewing your list of tasks can help you continuously prioritize all the tasks you need to do and organize yourself to accomplish them in the most efficient manner possible.

Combine trips.
If you are going to the ICU to do a postoperative check, you can check on the other patients while you are there and avoid a separate trip later in the day.

TEAMWORK

Surgery is a team sport. Yet as a new surgical intern, you may feel that you are not a crucial part of the team. Even if you are incredibly smart, you are unlikely to be making critical management decisions. So what does that leave? A lot, actually:

Keep a positive attitude.
If you are enthusiastic and interested, your residents will enjoy having you around, and they will work to keep you involved and satisfied. Enthusiasm also covers a multitude of the inevitable sins. A dazzlingly intelligent but morose complainer is better suited for a residency in the morgue. Remember, your resident is likely following 15 sick patients, gets paid less than $5 an hour, and hasn’t slept more than 5 hours in the last 3 days. Simple things such as smiling and saying thank you (when someone teaches, helps, or notices you) go an incredibly long way and are rewarded.

Work hard.
This internship is an apprenticeship. If you work hard, you will get a realistic idea of what it means to be a resident (and a practicing surgeon).

Embrace the scut.
Medical school is over, welcome to being a doctor. While we would all like a secretary, one is not going to be provided during your internship. And your residents do a lot of their own scut work without you even knowing about it. So if you feel that scut work is beneath you, perhaps you should think about another profession.

Help out.
If your residents look busy, they probably are. So, if you ask how you can help and they are too busy even to answer you, asking again probably won’t yield much. Always leap at the opportunity to grab admission/discharge forms, track down lab results, and retrieve bags of blood from the blood bank. The team will recognize your positive attitude and reward your contributions.

TAKING CARE OF YOUR HEALTH

Let me be honest: I (BCG) struggle with this issue-1 didn’t see a dentist for the first 3 years of residency, which is frankly disgusting. The standard advice is to exercise, eat healthy, and sleep as much as you can, but it is hard to do when you work >80 hours a week. I sympathize. But there are still some things you can do that don’t take that much time.

Eat healthy.
I love fat and protein, especially when I’m stressed, which is pretty much all the time in the hospital. But hopefully your cafeteria has some decently healthy food, or you can bring some from home. I would always rather have the bacon cheeseburger than the turkey sandwich without mayo, but I try and remind myself that I don’t need to eat every meal for enjoyment. One of the biggest drawbacks to eating healthy is, ironically,
cost. I know you will be an underpaid resident, but suck it up. Someday you’ll be making 6 figures and you can pay off whatever debt you accumulate from getting those fresh vegetables on your salad.

Walk the stairs.
I have a rule that I’ll walk anything less than 5 flights, and more if I’m not really busy. This is free exercise because waiting for an elevator is usually about the same amount of time anyway. Plus, research has demonstrated the significant positive benefits of even nonsustained aerobic exercise like this. Win–win.

Be disciplined with your sleep.
When I first started internship, I would come home post call and “hang out,” sometimes the whole day. Even when I wasn’t post call, similar things would happen in the evening, and I wouldn’t get to bed until midnight or 1
AM
. But I quickly learned how self-destructive it can be to not pay attention to my “sleep budget.” I know I need 7 hours to be rested. If I ignore those needs, my cognitive performance starts to deteriorate. Plus I just feel bad. And my GERD acts up, I get migraines, etc. So, I finally learned that I need to set a bedtime for myself and enforce it strictly. This can be particularly difficult if you have a partner with whom you are trying to spend time. But remember that you aren’t very fun to be around when you are exhausted anyway, and even less so when you develop major depression or an anxiety disorder (both incredibly common among residents). Residency is a marathon, not a sprint. Take the long view, and take care of your sleep.

Prioritize your loved ones.
Time is short, and there are many other competing demands. Bills need paying, dinner needs cooking, and the list goes on. But one of the most sustaining and healthful uses of your time is to spend it with those you love, whether a spouse, significant other, family, or friends. While relationships are the most significant determinant of human well-being, be careful not to cast the net too wide. Your sister’s college roommate is in town? Forget it, you don’t have time. Your second cousin once removed? Too bad, you can catch up after residency. I know it sounds harsh, but spending time with them means you are spending less time with those who matter most.

HAVE FUN!

This is the most exciting, gratifying, and fun profession you could ever hope for, and it is light-years better than whatever is second best. While there are challenges, the rewards continue to motivate us on our journey. We hope you enjoy yours as much as we have enjoyed ours. Bon voyage!

A 28-year-old Female Incoming Surgery Resident

Amanda V. Hayman, MD, MPH

Jennie, a 28-year-old fourth-year medical student, is thrilled—she just matched into the surgical residency of her choice. However, she is also apprehensive; her live-in boyfriend has agreed to move with her across the country, but she is worried if she will be able to maintain their relationship given the rigors of her chosen profession. She is also worried that, even if the relationship succeeds and they get married, will she be able to balance residency with raising a family? She’s unsure how to begin planning for this and doesn’t know of any role model to whom to turn.

1. What people could serve as resources for Jennie to discuss her concerns?

2. What expectations should Jennie set with her boyfriend about how her residency will affect their relationship?

3. What obstacles (prenatal, perinatal, and postnatal) will she face if she wants to have a baby during residency?

4. Name some healthy and unhealthy coping mechanisms for stress during residency.

WORK–LIFE BALANCE