A HITCHHIKER’S GUIDE TO INTERNSHIP

What you need to know as you step out of your comfort zone!

The transition point from the naiveté of being a medical student to a fledgling doctor that is the Intern is but the main exams one sits for at the completion of final year of medical school training. And in a matter of one single day post results declaration, you’re declared as a ‘supervised medical practitioner’ by your university and state medical councils in India. Facebook and WhatsApp statuses overflow with the cathartic release of profound exhilaration and relief as we feel we have finally earned the two hallowed letter prefixing our names for eternity – Dr. ABC has arrived folks! Pumped up with idealistic energies and untainted hope for a promising career ahead, we don our new white coats which we have upgraded to professional-looking full-sleeved white coats and sling our Littman stethoscopes proudly around the neck as we report for the first day at work. The excitement is palpable. Everyone has a Cheshire cat grin going from ear to ear as they high-five and compare their respective postings. After a brief pep talk, off we all go to our assigned departments. Internship year has begun!  As Day 1 progresses though, that buoyant energy ebbs away to be replaced by a haunting anxiety of committing blunders as we stumble our way through duty hours and tasks. Uh oh. We know theoretically all about Diabetic Ketoacidosis cause and management so much so that we ace our final year essays. But when you get a call from the Medicine ICU with an urgent plea to come see a patient in DKA who’s gotten agitated and unresponsive, you break out into a cold sweat. Your go-to persons, the postgraduates, are busy with their OP duties and other work. You’re on your own. Completely. So what do you do now? Welcome to reality finally people! You’ve reached the boundary of your comfort zone. Beyond - lies real life.  

Internship or our House-surgeoncy year in my high patient load tertiary-care medical college hospital in India was an ennobling experience. Like a coin with two sides, it comes as a great privilege and also a burden you have to bear. The privilege? To deal with patients on a first-hand basis, make diagnoses and also manage them, provide care and finally start doing the actual doctoring part. And yes, nothing trumps that entitlement feeling during the first few months of being addressed as ‘doctor’. The burden? Making the right calls regarding what ails the patient, what needs to be done, doing that at the right time and umpteen obligations you are now expected to satisfy. All this can be overwhelming. Been there! So I just decided to give you all a few life hacks I learned from the collective wisdom of seniors, peers and my own limited experiences which you can use during your legendarily grueling Internship year to sail smoothly. Read on;

Life hack #1: Being on time makes you be on top of things and avoid inefficient ‘hand-overs’

The foremost important message! Managing your time well is an art that has to be mastered. For starters, getting up early enough for morning Prerounds gives you plenty of time to study the patients and note their progresses in the charts. If not, by the time Grand Rounds start, you’re a sweaty nervous wreck with notes written haphazardly, incompletely and any question from the profs regarding a patient you’d rushed past out of the left field will leave you cutting a sorry figure in front of the big shots. Another more important consequence – the later you or your colleague report for duty to relieve each other, the worse becomes the ‘hand-over’ of patients from one shift to another. In her hurry to end her shift, she just breezes over the details of her patients to you and you find yourself in a dismal dilemma as to how to deal with the murderous stares of some patients who have already been waiting for a long while, sometimes missing to add a medicine or stop a medicine as the instruction has not reached you. Fatal mistakes that can and should be avoided at the cost of only being on time!

Life hack #2: Dealing with bystanders of adult patients

One of the most difficult parts of internship is not the endless hours you’re on duty but maneuvering your way around bystanders of patients. Now most of the patients themselves are not problematic and in fact obliging to cooperate with you but their overprotective, overbearing spouses or children regard you with skepticism writ on their faces. Some even put forth the fact bluntly and snub, ‘Have you even finished studying? Why doesn’t the senior doctor who was there for rounds come and see my husband?’ It will burst your bubble, trust me, to not to be taken seriously but here the key is to not lose your decorum or temper for that matter and explain to them in a dignified manner that you report directly to the senior doctor they were expecting and that you have been assigned by him/her to see to them. Be polite and gentle but firm. In most cases, they will calm down and let you do your work.

Life hack #3: Dealing with Paediatric patients and their caregivers

Tricky one this. Most children who get admitted are usually very sick and their caregivers which include parents, grandparents, uncles and aunties have their nerves frayed with anxiety. Any attempt at eliciting a history apart from the first time is met with tremendous irritation. This often happens when we are taking duties from another intern during the beginning of our shift. The parents have just detailed out the entire history to your friend but he couldn’t note down all points as he was called elsewhere and now you have to fill the case sheets. Before accosting them inexorably to run through the details again, try to gather all the information you have at hand, examine the child attentively and affectionately and then introduce yourself to the parents saying you have a few doubts regarding the history and if they would be kind enough to recapitulate it once more. Very unlikely that they wouldn’t.

Life hack #4: Drop that journalist-style note taking while eliciting history! 

We all develop this habit unconsciously during our early years in the wards. Terrified of missing out on a chunk of information, we all huddle around a ‘cooperative’ patient in the wards, bombard him with questions which he so good-naturedly answers while we do him the injustice of not even making eye-contact with him as our pens furiously scribble through the pages taking down the precious little nuggets of information. And as we evolve into Interns, this habit sticks on. To be honest, at this point, it would look rather unprofessional! Blatantly evident that you are a newbie and this is enough for patients to regard you contemptuously and perhaps even withhold crucial history points from you thinking you are way too junior to reveal that skeleton in their closet to. The result? During rounds, our senior doctor will unearth the skeleton easily and your history-taking skills might get appraised upon. What I try to do is go to each patient, listen to them while they relate their complaints, ask pertinent questions and complete the examination part making a mental note of salient points and then set out on filling the case sheet. This way, your direct eye-contact and manner bolsters an immediate rapport and trust. You can always then revert to them to fill any gaps after writing your case sheet. Another advantage would be testing your memory and attentiveness to reproduce the history you just elicited onto paper. A skill we definitely have to nurture to become good physicians. A note to my dear juniors as well – try to refrain from huddling around in flocks around patients if you can help it.

Life hack #5: Holding the nursing staff in high esteem

A departing senior shared this precious insight that to hold the nursing staff in high esteem and deeming them with respect can help you a long way. I say it with awe that it turned out to be so right! Right from informing us about a new admission or promptly notifying regarding the deteriorating condition of a patient to sharing their wisdom while we attempt procedures in the Emergency room and the wards for the first time, nurses are treasure troves of practical information next to your doctors whose no-nonsense efficient dealings live by the mantra ‘Give respect, take respect’. It’s an open secret that nurses and staff are notoriously uncooperative to high-handed arrogant interns/residents. We all share a common goal of efficient patient care and are a team. And it’s a humbling thought to be reminded that we are the newest and youngest link in the chain who can only grow by help from seniors.

Life hack #6: Do not disclose too much information!  

As Interns, we start to be directly involved in patient care and we are privy to a lot of sensitive information that come along our way. The fundamental dictum of Doctor-patient confidentiality has to take its roots here. As you step out of the ICU or room for instance after your Prerounds, you will be hounded by inquisitive and imploring bystanders who will beg, beseech and bombard you with questions regarding test results, diagnosis or prognosis of their loved ones inside. While it is downright rude to merely walk away without giving answers (remember that we might as well one day be on the receiving end, tables turned) it is also unethical to reveal too much of information to them – which should be ideally dealt with by the consultant. This tight-spot has no easy way out but with common sense figure out what all information can be safely shared, if possible. Otherwise, shut the heck up coz we novices do not have the experience of specialists regarding the significance of each test result/prognosis and you do not want to be responsible for unnecessarily alarming or reassuring patients’ bystanders.  As the age-old axiom goes, ‘A little knowledge can be dangerous.’

Life hack #7: Brace yourself well for Casualty duties        

During our days, circumstances provided only one Casualty intern on duty for 12 hours. It was perhaps the best and the worst times of the year. One was kept perpetually busy with hordes of patients flooding in from the door, handling their ailments, triaging them and calling the respective departments to refer their patients to. Every waxing and waning wail of the ambulance siren sends a shiver of anticipation and trepidation down your spine as you cast a glance at the already full ER. To handle the ER posting well, you need to have 3 abilities in my opinion – Nerves of steel, bowel of steel and a bladder of steel! To endure the gruesome sight of mangled limbs, broken bones and blood of accident victims and galvanize into prompt action, to keeping in check the alcoholic patient in withdrawal or the schizophrenic patient in delirium until the Psychiatric resident arrives requires you to fortify your nerves and not recoil from the challenge. On certain days, the very idea of it being lunchtime or dinnertime doesn’t even enter your mind as work piles up with you desperately trying to catch up. Getting to take a potty break becomes a luxury as you stay awake with bloodshot eyes. Brace yourselves and don’t complain. For these are the very experiences that will carve out the best in you in the coming years.  Deal with belligerent bystanders in the Casualty in a firm and professional way. In the throes of their anxiety regarding their loved ones you are tending to, they will scream, intimidate and badmouth you to draw out some information but hold your ground. Under no circumstances, allow them to bully you or treat them back discourteously or angrily. This will only go downhill for you, the patient and the hospital.

Life hack #8: Do not take rebukes to become regretful and disillusioned

Let’s face it. We might screw up colossally at times. Maybe due to ignorance, exhaustion or other reasons. Some departments are invariably easy-going and some, well not so much. The take home point here is to take every censure and criticism positively and not lose heart. Find out where things went wrong and make amends. No one was born perfect in this world. And this is our learning curve – it might be sigmoid for some, steep for some or even plateau out for some. Stop comparing with others. It may not seem rewarding at times in contrast to the work you put in and you will develop disillusionment and disappointments easily. Just remember that there’s light always at the end of the tunnel.

Life hack #9: Figure out what interests you now!

Your career is at its threshold of blossoming and now is the perfect time to figure out which specialty you would want to specialize in. Instead of fielding questions regarding your career goals or dismissing them away, give it serious thought. As you work your way through each department, ask yourselves this: Do I see myself working in this specialty in the future? Can I do it? If the answer is in the affirmative, you know what to aim for!

Life hack #10: Don’t live under a rock!

Internship is a state perpetual exhaustion and we are considered as near ascetics by family and friends. We become oblivious to the world revolving around us and have to miss out on several occasions due to tight schedules. While it is imperative to take our work seriously, it is also important to strike a balance with your social life which, in our early-mid twenties takes a turn to be rather active. Be there at your sibling’s/cousin’s wedding to witness the blissful union, be there on your parents’ anniversary, be there to meet up with a friend who is in town after years. These precious moments are rare to come by. It will also serve as a chill out time to save you from a burnout!

Bottomline: Enjoy the Internship year. We get only one shot at it. Work, laugh, share, learn. Embrace the challenges thrown your way and learn from each experience. This is the time to be tested by adversities, petty humiliations and hardships to emerge wiser and stronger. Smooth seas never made a seasoned seaman! And of paramount importance, master the art of communication with patients – your panacea for success. Primum non nocere fellas!

Dr. Sridevi Rajeeve

Alumnus, 2008 Batch
Malankara Orthodox Syrian Church Medical College Hospital, Kolenchery, Kerala, India
Affiliated to Mahatma Gandhi University

P.S: Primum non nocere is one of the cardinal rules in the Hippocratic Oath. Originating in Latin, it translates to ‘First, Do No Harm’

THE ENGLISH LESSON

A poem from my childhood, with which my fascination for the English language started. Read on to know why!  The English Lesson by Richard Krogh       (Published in the 1800s) We'll begin with box, and the plural is boxes; But the plural of ox should be oxen, not oxes. Then one fowl is goose, but two are called geese Yet the plural of moose should never be meese. You may find a lone mouse or a whole lot of mice, But the plural of house is houses, not hice. If the plural of man is always called men, When couldn't the plural of pan be called pen? The cow in the plural may be cows or kine, But the plural of vow is vows, not vine. And I speak of a foot, and you show me your feet, But I give a boot - would a pair be called beet? If one is a tooth and a whole set are teeth, Why shouldn't the plural of booth be called beeth? If the singular is this and plural is these, Why shouldn't the plural of kiss be nicknamed kese? Then one may be that, and three may be those, Yet the plural of hat would never be hose; We speak of a brother, and also of brethren, But though we say mother, we never say methren. The masculine pronouns are he, his and him, But imagine the feminine she, shis, and shim! So our English, I think you will all agree, Is the trickiest language you ever did see. I take it you already know Of tough and bough and cough and dough? Others may stumble, but not you On hiccough, thorough, slough, and through? Well done! And now you wish, perhaps To learn of less familiar traps? Beware of heard, a dreadful word That looks like beard and sounds like bird. And dead; it's said like bed, not bead; For goodness sake, don't call it deed! Watch out for meat and great and threat, (they rhyme with suite and straight and debt) A moth is not a moth in mother. Nor both in bother, broth in brother. And here is not a match for there. And dear and fear for bear and pear. And then there's dose and rose and lose -- Just look them up -- and goose and choose. And cork and work and card and ward, And font and front and word and sword. And do and go, then thwart and cart. Come, come, I've hardly made a start. A dreadful language? Why, man alive, I'd learned to talk it when I was five, And yet to write it, the more I tried, I hadn't learned it at fifty-five!