A Day in the Life of an Intern
Welcome, inaugural interns! You are a class like no other, except very few in the United States. You are our junior, yet at the same time, are our most senior residents. Your internship will be at the very least challenging, intriguing, and satisfying in character building. Though your ratio to faculty members is almost 1:1, never think that this will take away from your independence and ability to shape and improve your clinical skills.
The cardinal feature of a successful physician is that he has the ability to make decisions with confidence, and every decision that he makes is done with prior thought as to the consequences (both good and bad) before the decision is made. And in no specialty is this skill as important as it is in internal medicine. Internal Medicine is not a game of checkers, where you merely respond to your opponent's move. It is a game of chess… where every move must be made by thinking four, five, six moves down the game. Unlike the surgeon who can bovie his mistakes, the internist cannot take back the beta-blocker she injects into the IV.
The ability to quickly make decisions with confidence is what will define your excellence- that is for sure. And mastering that ability comes from only one road: continual practice in making decisions. DHR is a program built on autonomy under appropriate supervision, with residents routinely and consistently put into the position of making decisions. After two years of doing this, our third-year residents will operate like faculty. And in any great residency program, this should be goal.
Our philosophy is to match that of our teaching hospital here at DHR which was built on two principles…avoid fragmentation and practice makes perfect. Always sharpen your time management skills and start tasks which you know you will complete within the allotted time. The DHR day is built to honor this essential principle… "Practice doesn't make perfect…. Perfect practice makes perfect." We are a clinical learning environment where everything is geared towards learning and teaching.
YOUR DAY: NON-CALL & NON-POST-CALL DAYS
7:00 - 8:00 AM: Pre-rounds
The day starts with transfer of care from the night float team to the day call team. An important element of learning medicine is mastering the "transition-of-care." See it as the metaphorical equivalent of a track relay team passing the baton…. You can run the best race of your life, but if you drop the baton, it is all for not. As part of the curriculum, you'll learn the cutting edge techniques of closed-loop communication, transitions-of-care essentials, and contingency planning. Sign out is done in the same place, regularly at the same time. This is a face-to-face procedure with all relevant patient information generated through our Cerner EMR and reviewed by both teams. At this time, the night float team is resting until the morning report. The pre-rounds then begin which should not take more than a half-hour. Each resident eyeballs his own patients and pays extra attention to the sick ones or those who had a change in condition during the night or as reported by your night float team. If the patient is sick, call your senior and stay with your patient, even if morning report has started. The purpose of pre-rounds is to gather the necessary information to make management decisions about your patients. Then there are the visits to each patient where a focused history of the events overnight is obtained, and focused physical examination is performed. This reassures the patient that you will return multiple times during the day to spend more time with them, and that sets you up for not only efficient pre-rounds, but also for developing meaningful relationships with your patients.
8:00 - 9:00 AM: Morning Report
This is the most interactive and challenging teaching multi-disciplinary exercise during your three years of training which on a daily basis will shape your professional character and improve your excellence in practice. Morning Report begins at 8 AM each day and includes the entire team, including the attending physician. An exercise in group learning and teaching experience and at times will be review of the most recent, updated information regarding disease entity. The case presented (power-point presentation) is selected by the night float senior resident and none other.
9:00 - 11:00 AM: Attending Rounds
Attending rounds begin at 9:00 AM at each hospital. The team walks in unison during rounds to see each patient in person. Attendings do not write full notes while on rounds, but rather spend the time seeing patients with the team, and reviewing the decisions the team made during work-rounds. Teaching occurs at the bedside, just the way medicine was meant to be practiced. All management decisions are made during resident rounds by the residents, and the attending / resident leading the team will begin the discussion of each patient by asking you what you want to do for the patient. While it may seem intimidating at first, this is the first step towards becoming the master clinician. Soon your whole way of thinking will change to that of being in control… and responsible. The expectation is that the team will have an assessment and plan on each patient prior to attending rounds. This will allow the attending to check your work, provide advice or modifications, and to spend most of his or her time teaching you about your patients.
12:00 Noon: Noon Conference
A teaching didactic conference covering core topics in general internal medicine, geriatrics, all the medicine subspecialties, and featured topics from other specialties such as rehabilitation medicine, ophthalmology, ENT, and dermatology. Conferences during the first two months of every academic year are geared to providing the interns with the skills needed to manage acute medical problems.
1:00 – 5:00 PM: Resident Management Rounds on their patients
(including discharges that did not occur during attending rounds)
This is an opportunity to advance patient care, do procedures, or teach your medical students. This will be a great opportunity to practice the "coaching skills" that Dr. Malas will teach you. Remember, since the ward services are supervised by full-time faculty and adjunct teaching hospitalists (who have not competing time commitments) you will have someone there throughout the day to help you with procedures, answer questions, or teach you.
Importantly, having the afternoon to complete patient care tasks and to engage in the fulfillment that comes with teaching (or being taught) greatly reduces the "intensity" of the day.
5:00 PM: Sign-out
Hey, when you are done, you are done. When patient management is completed, and you have done (or received) appropriate teaching…. It's time to leave. Duty hour rules are NEVER to be violated. Your shift is ending, you sign out to the on call team and you leave the hospital. Before you leave though, you'll want to sign-out with Cerner.
5:00 – 8:00 PM: Day On-Call Team On Call team responsible for management of all medical service patients and any consults from other specialties admitting patients and running the code. This is a continuation of the 1-5 p.m. resident management rounds minus the residents who are not on call that day.
Another standard transition of care hand-off occurs between the on call day team and the night float team.
8:00 PM – 8:00 AM: Night float
Usually consisting of a resident and an intern, this team is responsible for the care of patients on the University Medicine services. Urgent or emergency consultations only. No pre-op clearance will be performed by the night float team for elective surgery. The night float will admit patients according to the CAP rule, 5 admissions per intern. These patients will be signed out in a proper formal transition of care format to the on-call day team. The night float team is expected to attend the morning report and present one of the cases admitted or the presentation can be done by the day team call. After 9 a.m., night float team is relieved from his duties and has no direct or indirect patient care or contact.
Night float are off every Saturday for 24 hours.
Night float team are the only team excused from continuity clinic.