From intern to third year: Making the most of your residency training

The first time I put on my long white coat, my hands were shaking. I was an intern starting my internal medicine residency. This was the first time there would be “Dr.” put before my name. All I wanted was to be the best intern I could be and the best doctor for my patients.

Now that I’ve just finished residency and am starting my nephrology fellowship, I reflect on where I could have improved and what made residency great. As many new doctors and current residents prepare for this upcoming year, I’d like to share my advice from intern year to third year on how to make not only your years of training great but also how to build a residency culture that promotes learning and growth.

Intern year: Learning how to be a resident

Interns! Congratulations! You’ve matched into a residency. This is a huge achievement; take a minute to be proud of yourself.

Intern year is when you learn how to function as a resident physician. This is when you learn the culture of your hospital and residency program. You will learn how each attending likes to round and what they prefer to order. You will learn how to use the EMR and who is the best person to consult on a Tuesday for hyponatremia. These are things they cannot teach in medical school, so be prepared to feel unprepared when you start.

As an intern, your biggest goals are to learn how to work within your team, in your residency program and at your hospital. If you are positive, willing to learn, on top of what you’re told to do and open to criticism, you will go far.

My biggest advice to you, my dear intern:

• Practicing medicine is a lot like learning a new language. Medical school gave you the vocabulary, but now you’re being dropped in a foreign country where no one speaks your language and all you have is the vocabulary you learned. This is especially true if you matched into a residency that is different from your home hospital in medical school. Every hospital has a different culture. Be open to learning the culture of your hospital. Do not be afraid to ask your seniors even the smallest question. You are not supposed to know everything.
• Listen more than you speak; during rounds, even if you are not presenting, be engaged. This will make you a better team member and you never know if you will be assigned that patient the next day.
• Learn how to take criticism. If they tell you to adjust medications or disagree with your plan of care, listen, ask questions if you do not understand and thank your senior or attending for teaching you. A simple, “Oh, I did not know that, thank you so much, I’ll put that order in now,” does wonders. Remember, we are all on the same team and attempting to bring the highest quality care for our patients.
• Write everything down. When your senior resident or attending physician mentions an order that needs to be done or a lab that needs to be followed up on, write it down. It helps to have a checklist so you can be sure you have done everything before you leave. It is also helpful to carry your laptop or tablet on rounds so you can place orders after your senior or attending mentions them. With the constant ebb and flow of patients and information, it is best to put in orders as soon as possible during rounds so they can be followed up on after.

Second year: Embracing independence

Welcome to second year! Every program is run differently, but the ideal program allows second-year residents to stand on their own two feet. While interns are busy learning how to put in orders and third years are busy watching the interns put in orders, this is your time to learn how you want to practice medicine.

As a second year, you should be allowed more independence. You have worked at your program and hospital long enough that you know the culture and can defend your medical reasoning to your attendings. Be thorough and be sure you have looked up the most up-to-date evidence-based medical guidelines.

Second year is a unique experience where you are in between the new residents and those leading the team. While you may not be the leader, you are still a role model to interns and medical students. Answer questions, help when you can and realize that you also influence the culture of your residency.

When I was a second year, I had third years try to dump work on the interns with little guidance. During my third year, I told the team that our interns were struggling and talked about what we could do to give them more support. We worked together to make the environment more collaborative, which improved patient care, as tasks were being completed in a more timely manner.

Third year: Leading the team

Hello, third year! Are you excited about graduating? Have you decided on a fellowship yet? In an ideal program, you now are the leader of the team, so how do you run the best team your attendings have ever seen? I’ll show you.

As a third year, you are the most experienced person on your team. Interns and second years are relying on you to teach them how to be a resident. This is your time to grow as a leader and prepare to become an attending who leads a care team.

At the beginning of the rotation, set your expectations with your interns, second years and medical students. This is highly program-specific; think of what would have helped you at each step of your career.

For example, I tell the medical students specific tips on how to present patients and what our attendings expect in a physical exam and chart review. I also take the time to explain how and why we do things.

As an intern, I had third-year residents who did not stay with the interns. They would ignore the interns until they messed up and then berate them for not knowing how to do a task. This is not a healthy environment or residency program.

This creates a hostile workplace and makes interns feel like they cannot ask questions. Remember, patient safety ultimately is your responsibility. Treat all patients how you would want your family members to be cared for. If an intern becomes defensive and scared to ask questions, patient care will suffer.

Expect your interns to know nothing and to forget everything. You need to know every patient and every task the attending expects for every patient. You need to listen and be active in rounds as much as your juniors. Know the patients well enough that if a resident is pulled to a patient emergency, you can round with the attending as if it was your patient. Follow up with your interns after rounds to run the list and make sure they understand each task to be done.

Your second-year residents should be allowed independence to learn. As the third-year resident, you are responsible for teaching the interns. You should be there to answer questions for the second-year residents but otherwise, give them patients to help them grow and allow them the space to do so.

If you are having problems with a junior resident, pull them aside and ask them what is happening. Get their perspective on what they feel is going right and wrong before you jump to conclusions. What may look like a lazy resident might in fact be a resident who was never told the expectations of their role and what tasks to complete.

Finally, understand that you are in control of the culture of your program. You can make the program malignant by doing the bare minimum, never checking over your juniors’ work, throwing your juniors under the bus to attendings and never speaking to the junior residents who are struggling.

You can also make the program a wonderful learning environment by answering questions, being available, knowing your patient list, speaking to struggling residents first before escalating the issue and being kind and calm under stress. Be fair, pay attention to your teammates and dive deep into your leadership role.

Medicine is ever-changing, and the culture of your healthcare team often is as well. If we work together and fulfill each of our roles in residency, we can create a positive experience that grows strong doctors who are confident in their education and training.

Editor’s note: This story was edited for The DO by Jane Datinguinoo, OMS III. The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.