new medical intern on the service.... need advice

arnie1234 · Jun 26, 2011

Welcome

1. Be respectful of everyone- nurses, techs, housekeepers, your patients and their families.

2. Don't lose the human touch aspect. It is very easy to forget that your patients are someone's mom, dad, brother, sister, etc.

3. Remember that it's okay to have a bad day and not be yourself. Just don't forget to apologize if you have one and take it out on the nurses or others.

4. Build relationships with the nurses, you will come to trust their judgement once you have built a rapport.

Be kind, learn and grow as a professional. Communicate clearly and frequently.

Whispera, MSN, RN · Jun 26, 2011

Remember that taking care of people is a team thing. Members of the team include the doctor, the nurses, the patient, the aides, and the patient's family members. The patient is the leader of the team. The other team members are only doing for the patient what he or she can't do for self. All members should be respected and their input should be valued....

heron, ASN, RN · Jun 26, 2011

Accept that you will run into dumb nurses just like we run into dumb docs. Don't waste time battling with them. In time you will learn which nurses you can trust.

Think carefully about your orders:

Are there adequate prn's to avoid the dreaded 3AM nonsense call to the night float? This can get tricky ... talk to your resident or attending to learn what/how to order prns without creating problems down the line.

Know your facility's policies re orders ... for instance, if policy requires parameters for certain meds ... write them. Don't make nursing staff chase you down to fix paperwork.

If you write, "Call MD for ... ", don't get upset when we do.

Also, learn to love teaching. You'll be doing a lot of it during your training. We'll love it if you practice on us by answering our questions and explaining your line of reasoning.

As noted above, courtesy is key ... and works both ways. Don't disrespect nursing staff and don't tolerate disrespect towards yourself. Back us up when we're right and talk to us when we're wrong. Resist the temptation to automatically throw nurses under the bus when there's a problem.

Know that we have a license, too, that carries certain responsibilities that do not fall under your authority as the MD. These primarily have to do with patient safety ... if a nurse refuses to do something, there's usually a reason.

Cultivate a sense of humor.

You are not here for the nurses' benefit nor are we here for yours. If it isn't about the person in the bed, you're wasting your, our and the patient's time.

canesdukegirl, BSN, RN · Jun 26, 2011

Oh wow! I am so impressed with you already because you came to this forum to ask your questions! It is docs like you that I admire, because you see the VALUE in developing good relationships with nurses. Kudos to you!

1. My expectation of interns is that they develop good communication skills. State your expectations clearly and if you have any doubts, ask your PGY2. It never hurts to ask nurses directly what they think about your plans/expectations, but be confident when doing so. Example: I worked with an intern who was a very bright young woman and obviously had her "stuff in a pile". She was organized, decisive, and direct. She learned quickly that certain nurses would be helpful to her and was not hesitant to ask help from those nurses. She had her doubts at times, so she asked pointed questions in order to formulate a sound decision. When she didn't know the technicalities of a simple procedure (i.e., drawing blood for cultures, taking out skin staples, applying a Dakin's dressing), she would find one of us to show her how to do it. She collaborated with her attending, her PGY2/3 and the nurses taking care of the patient to come up with a truly multi-disciplinary approach to care. Needless to say, she was super successful and a favorite among her peers.

On the flip side, I worked with an intern who was quite frankly terrified of everything. She was a bright woman, but she was incredibly insecure and did not trust anything about herself. She was unorganized and did not know the answers to basic questions when she came into the OR to report off to the PGY2. She was skittish and her demeanor did not inspire confidence from her patients. She quit the program after one year.

The point I am trying to make using the above examples is that on the one hand, you should be confident (but not cocky) and on the other hand, you must be brave enough to ask questions prior to rounds so that you don't look like a complete fool in front of your patients and your PGY2/3. Most nurses love to see interns grow and blossom. A good working relationship is key.

2. I think that I answered this question already with the above scenarios. When you are approaching a nurse that you haven't met, introduce yourself and tell them that you will be the intern for X number of months for that service. If there is a whiteboard on the unit (usually at the front desk or in the lounge), write your name and pager number on the board.

3. Pitfalls-oh lordy! There are so many! If you are as organized as you can possibly be, you will have already won half the battle. There is nothing more heart-wrenching to me than to see a new intern pull out a wad of papers, shuffle through them (all the while sweating bullets) in order to answer a simple question during rounds. If you can somehow create a notebook in which you can staple your rounding papers in, it will make your life easier.

One of the most common pitfalls I have seen is a very tired, hungry intern. Mistakes are easily made if your blood sugar tanks because you haven't had time to eat. Keep a jar of peanut butter in your locker so that you can at least have a tablespoon or two before running to put out the next fire. You will be surprised how well this staves off hunger. Also, eat some protein for breakfast. Boil some eggs the night before so that you can throw them in your bag before you go out the door at O'Dark Thirty.

Keep your home study area organized. One of my BFFs is now a Chief, and she is just now getting around to organizing her study. I made files for her and set up some bookshelves, grouping her texts together by subject. You are gonna be dead tired when you come home, and the frustration of not finding something does not make for a good start the next morning. It's much easier to keep things organized as you go.

Make friends with the unit secretary. They will have your back if you treat them with respect. And THEY KNOW EVERYTHING! Seriously, a good unit secretary will know exactly how/when/where to get something if you need it.

Good luck to you!

A&OxNone, MSN, RN · Jun 26, 2011

High five on the secretary tip, Canes! I was a sec during nursing school, and I swear, interns underestimate you!! I know where paperwork is, what labs are usually ordered... ect. Your secretary can be your biggest helper! :)

And plus, even now that I'm a nurse, you couldn't pay me buckets of money to have that job again! Our ER sec is SO stressed out and being pulled in so many directions - phew. No thanks anymore. :)

nurseprnRN, BSN, RN · Jun 26, 2011

never, never forget that an experienced, strong nurse already knows more than you do and has seen a lot more than you have. you will learn more medicine, eventually, but you will never learn as much nursing.

take ten minutes to look up the ana scope and practice of nursing online (if you can't find it, email me and i'll send you a pdf copy.) you will have a much better basis for your own practice if you know that. nursing is not "what the doctor wants to be done." physicians do not hire, fire, evaluate, or discipline nurses. nursing is an autonomous profession with our own body of knowledge and skills, many of which may overlap with yours and many of which do not, and without those our patients would not be ok. remember that the medical model of illness care is not the same, and does not spring from the same conceptual framework, as the holistic model of nursing. complementary, but never assume everyone sees a patient the same way as your med school faculty.

corollary to that: don't ever call it "doctor's orders," call it a "medical plan of care." ask what the nursing plan of care is. listen to the answers. we work together; you don't give us orders. yes, it is expected that we will implement the medical plan of care; but don't forget, we are also professionally responsible for evaluating its safety and to ask you if something doesn't seem right. listen carefully if somebody says something about that and explain your reasoning; both of you will learn something.

if you have to do something new and your pgy2...x can't hand-hold you through it, never be afraid to ask an experienced nurse to accompany you. tell him/her it's your first one, ask what you should do. we are looking out for the patient's best interests, so we will make sure you do it right, no worries. i have taught a lot of 1st-yrs how to pull chest tubes by saying,"now, mr. smith, dr. jones is going to remove that tube for you. i'm going to explain it all to you before we start. first, s/he's going to snip that suture; that won't hurt. then s/he's going to ask you to take a deep breath and hold it, and then to give a big cough as s/he pulls it out. that will hurt, but it's over fast, promise. then s/he will tighten up the suture around the place where it was, and i'll put a little dressing on it. want me to say that again?" then as the 1st-yr starts, i'd repeat it step by step "to the patient."

never, ever get high-and-mighty, not just this year but for the rest of your career. every nurse knows some (and, sadly, not enough) physicians for whom we would walk barefoot over broken glass because of their clinical competence, exceptional kindness to patients, and collegial (not just polite, but collegial) relations with nursing. strive to become one of those. your patients will benefit.

good luck, dear. drop by from time to time and let us know how you're doing. we're nurses, we can help.

heron, ASN, RN · Jun 26, 2011

And please note, SDN notwithstanding, NO ONE has advised bringing in donuts.

msjellybean · Jun 26, 2011

Please please please think about what labs you want before you order them.

So many times my patients have been stuck for something and then the intern or resident decides they want another lab drawn. So lab comes back. And then an hour later, the process repeats. No one likes being stuck 3 times when once could have gotten it done.

lalalalexi · Jun 26, 2011

My big things are:

*Listen to the nurse if he/she says they are concerned. I can't tell you how many times myself or another nurse has been concerned about a patient and call the doc or resident and ask them to come and see the patient and they don't do it. We generally don't ask you to come to the floor at 2am unless we think there is a reason for it. My favorite resident this past year would come up no questions asked if we ever had a patient issue that we thought needed direct attention.

*Listen to the patient. Patients know their bodies better than anyone, so if they say they're experiencing something unusual, look into it.

*Write your orders, or anything else you expect us to read, legibly. I know you're in a hurry, but so are we! A few extra seconds to make your handwriting legible makes a big difference in our lives. We have one resident who has pristine handwriting and we tell him we just want to give him a big hug all the time!

*Speaking of orders, flag them when you write them, or better yet, let us know! I hate looking at a chart and realizing orders were written 2 hours ago and no one flagged it or bothered to let me know. If you write orders for something you want done stat or now, or something that you think is important, find the nurse or give them a call. Another great resident, no matter what order she writes, will either track us down or give us a call to let us know she wrote an order. I appreciate that so much. That also allows us to ask any questions about it if needed, and a lot of times we DO have questions and will need to call you back anyway...

*Be nice. I love building rapport and trust with my docs and residents. It's nice when they know you by name (I know a lot of times it's too hard to remember everyone, but it is nice when someone remembers your name). When you see other staff in the halls, say hello, or good morning, or smile at them. It's just a pet peeve, but I cannot stand those residents who saunter up to the floor every morning, and walk right past you without even looking at you. Healthcare works best when it's a team effort, and I like to feel like I'm part of the team, not some invisible minion to carry out your orders. Ask me how the patient is doing, ask me to join you while you round on a patient, include me in your decision making process etc. Nurses are valuable resources, and if you're nice to us, it actually benefits everyone!

anotherone, BSN, RN · Jun 26, 2011

Hello,
I am a new intern starting my residency next week. It is a big transition from being a medical student to a newly minted doctor and I want to make sure I am off to a good start. I will greatly appreciate advice from nurses regarding your views on:
1) your expectations of interns
2) tips for effective communication
3) any potential pitfalls to avoid
Thanks so much!

1) med reconcilliation when admitting pts.

2) ask the pt if they have any questions, let the pt know what is going on.... so many times pts are afraid to talk to "THE DOCTOR" so they tell the nurse. then i have to page the md who was just there a few minutes ago. Also I encounter a lot of pts who have no idea what they are being treated for or his/her diagnosis. Nothing like telling a pt," you can't eat or drink after 00:00 (NPO for some test)" and he/she has no idea what i am talking about or what it was ordered for........awkward......

If you are returning a page, when i answer the phone tell me, this is dr. "so and so" or " i am with internal medicine, or with gen surg, or ent" ......... sometimes I page more than one dr at a time for different patients. or the dr calls back an hour or so later and just starts talking on the phone..... If you are taking call from home and order something let me know it is a telephone order. Some specilties at my hospital take call at home but the person on call may very well be in the hospital so i don't know whether they are there and will put in an order or excpect me to put it in.(some drs tell you what they will order on the phone and put the order in afterwards). If you are giving a telephone order wait until i read it back to you before you hang up.....

3)If you are admitting someone who will need a medication titrated, some type of drip, cpap/bipap make sure you admit them to the right floor (med/surg, vs tele, vs icu vs a stepdown etc). prob facility dependent. some med surg floors don't do certain drips.

If you order "notify md for................. "don't get annoyed when notified.

ChristineN, BSN, RN · Jun 26, 2011

Wow, I also think it's great that you came to a nursing forum for advice!

If a nurse calls you to tell you that you should come see a pt, even if it seems like thing, come see the pt. I don't call and wake you up at 2am for the hell of it. If I take the time to call it means I'm generally concerned that the pt is deteriorating in some way

Don't be afraid to ask your Senior or the consulting services for advice. They all know that you are new, but they don't know what is going on with the pt or that you are unsure of what to do unless you tell them.

When working on discharge planning, keep in mind your pt's insurance status vs self pay. I've seen docs have all great ideas of some new awesome drug, but it doesn't really help if the pt can't afford it or if insurance refuses to cover it.

When you round, try to take a few min to ask the nurses if anything happened overnight that you need to be aware of. Just because we didn't page you didn't mean that you might want to know about decreasing PO intake or other things that I wouldn't normally bother paging over.

Know what the floors of your facility are/are not allowed to do. At my facility you can't give IV BP meds unless the pt is on a tele floor, so if you order scheduled IV BP meds on a non-tele floor, we'll have to move the pt to a different floor.