Top tips for new interns [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“New resident physicians who have earned their MD degrees will be heading to hospitals to start their residencies during the last two week in June and the first week in July. What can a beginning doctor do during the first month of internship to get his or her career off to a good start, and in so doing, also learn to provide the best care to patients?”

Vijay Rajput is an internal medicine physician.

He shares his story and discusses his KevinMD article, “Top 10 things new interns should do.”

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Click here to earn 1.0 AMA PRA Category 1 CME for this episode.

Also available in Category 1 CME bundles.

Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Vijay Rajput. He is an internal medicine physician, and his KevinMD article is titled “Top 10 things new interns should do.” Very relevant at the start of the academic year. VJ, welcome to the show.

Vijay Rajput: Thank you, Kevin. Nice to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Vijay Rajput: I was born and raised in India and did medical school in India. In India, we go from high school to med school. I completed medical school, wanted to be a surgeon, finished general surgery, and wanted to be a plastic surgeon. I started dating a classmate who had relations here in the United States, and I came on a chain migration to the United States in 1992, to Philadelphia, in March. So I ended up taking a transitional rotating internship, and then my wife said, “Oh, you better find a short residency rather than surgery, plastic surgery.” So I ended up matching at Robert Johnson Medical School in Camden, New Jersey.

And that’s it. From 1993 to 2015, I spent my time in internal medicine academic practice and as a medical educator. And then things changed in my life, and for the last five years, I’ve been in Florida, where I have been, now at Nova Southeastern, as a department chair of medical education, and I still teach medical students and administer medical education.

Kevin Pho: Now tell me, as a medical educator, what are some of the challenges and rewards that you face daily?

Vijay Rajput: The challenges are the same. I treat a patient and a learner in the same way. I think you do the same thing for a patient, and I think it’s the same thing to do for the learner, and I have sort of used similar principles. Both require listening, both require caring, and both require going a little bit of the extra mile. You have to end up doing something not in your job description. I think that’s a simple principle for my students, residents, and patients.

But the challenges are contemporary, and I think the biggest challenge I really worry about is the shift from the bedside. That mindfulness, giving 100 percent to my patient, is being interfered with by a lot of minutiae, or whatever you call it, whether it’s a computer or my iPhone or my pager or that distraction. And I’m trying to figure out how I can bring my learners and my residents to give that 100 percent to my patient when they’re in the office or the ER or at the bedside. But that’s the biggest challenge I see in clinical practice.

Kevin Pho: Now, you’ve been working with medical students and medical trainees for a while now. Have they changed over the last five, 10 years? Have you noticed any changes?

Vijay Rajput: I think they are still good students, so I don’t want to take any. And they are learning in a different way, so I think we all need to figure it out and adjust ourselves. My biggest concern, and that may be part of us, is this understanding of work-life balance. I really believe that the medical profession and your personal life are a juggling; there is no balancing act. You are constantly juggling.

And I still remember one of my professors told me, “VJ, in your life, there are three crystal balls you’re going to constantly juggle. One is your personal life, one is your academic professional life, and the third is integrity. And you have only two hands, so you can’t break the integrity, because if you break integrity, you don’t have any of those. So the two other things you’re going to juggle, and the issue is how far you throw them up in the air. You want to make sure that you don’t throw them so far up that you will break that part, whether professional or personal life.”

But I think that’s where the challenge is. I really believe work-life balance is not the right way to go in the medical profession. We need to train our learners and residents to get used to how to juggle your professional career and your personal and family life.

Kevin Pho: All right, so you give more advice in your KevinMD article titled “Top 10 things new interns should do.” As we all know, July 1st is the first day that graduated medical students go on to clinical rotations, and it’s really jumping into a completely new world from medical school. I remember when I was an intern, my first day was night float, and I remember just yesterday, I was a graduated fourth-year medical student, and the next day, people were calling me overnight for all these issues for people in the hospital. It was such a big jump for me. So tell me about your article. Talk about it for those who didn’t get a chance to read it.

Vijay Rajput: Yeah, so the reason I came up with it is because I have done three internships in my career. One is surgery in India, then I did a rotating internship in Philadelphia, and then an internal medicine residency at Robert Johnson Medical School. And every time, I thought, “I have already done two internships. I’m pretty smart.” And then I realized that I struggled every time. Then I realized there are things which are simple, but they’re not being told. It may be as simple as “start early” or “get help from the nurses or everybody.”

So that led me to come up with these 10 important points, which really have nothing to do with medical knowledge or your specialty or expertise, but are simple things you can instill right at the beginning of the internship. And if you carry them with you, I think that’s how I became a better doctor, I’ll tell you. That’s the whole reason. And some of those are as simple as asking for help. Nobody teaches it.

And the reason is, I remember I’ve read somewhere the two things, when a student becomes an intern, that they fear: One is they don’t want to look stupid, and they don’t want to hurt anybody, right? On the first day, I’m sure, when you became night float, Kevin, you really were worried about making sure you didn’t hurt anybody and you didn’t look stupid. So those two things stay with you. And all these 10 things that I have said can help you to overcome that, whether it’s getting up early and asking for help, or just being early, or being more effective rather than efficient.

And I know the way we have created a system, efficiency is rewarded. We know that. And your residents say to the intern, “Oh, you better get it done, this H&P,” rather than, “Oh, I’m going to take a little bit longer.” And then duty hours came, and then duty hours really made people become more and more efficient rather than effective.

So those are simple things, even like thinking about rescuing rather than treating complications. I still remember the ICU fellow would come, and they would not take the patient into the ICU early. And somebody’s saying, “Oh no, you need to take the patient and prevent the complication.” But you will have that patient crashing on the floor, and then you rescue it, and then everybody says, “Oh, we saved the patient.”

So those are simple things we can do, as simple as, when writing a prescription, thinking about allergies all the time and thinking about the way the drug is metabolized, and liver failure. And the most important thing I tell residents is that everybody is watching you all the time. Make sure: You are watched by everybody. So those simple things can make you, I think, a better resident and a better intern, and you can practice well the rest of the time in your career.

Kevin Pho: Now, when people graduate medical school, they already have to have a lot of skills just to make it through that whole premedical school process, and then medical school, and then finishing medical school. What are some added skills that interns and residents should have that aren’t necessarily taught in medical school?

Vijay Rajput: Yeah, that’s an excellent question. I have called that the zero milestone, the zero-hour milestone. So you’re graduating from medical school; nowadays they call them EPAs. And on the very first day, a simple skill is calling a consult, right? Nobody teaches you how effectively and efficiently you can call a consult in two minutes and explain to the consultant very effectively what you’re really looking for. As simple as this.

The second one is pronouncing a patient, which you see lately in the literature. But I will tell you, nobody ever taught me how to pronounce a patient. And not only pronouncing, but the patient in crisis. Nowadays, patients die in the hospital, end-of-life care, palliative care. Even in those situations, nobody tells you how to do those.

So it’s as simple as calling for a consult, and the rest is just talking to your peers and how to effectively communicate with the nurses, calling and talking to the ERPs, calling the ICU team, calling the OR team. Those nuances, I think we are still not teaching our residents very well. Nowadays, there is a movement called transition to residency, TTR, and there are schools now developing a couple of curricula, but still, I think it can be integrated very well across the curriculum and make students ready for that zero-hour milestone.

Kevin Pho: So one thing that you mentioned was the relationship with the support staff and the nurses, and I think that’s absolutely critical, because they can make or break your intern and residency experience. So talk more about how new interns can build those relationships with the nurses.

Vijay Rajput: So the most important thing is to introduce yourself to everybody, which starts from your security desk at the front of the hospital. It can go to the janitor. It can go to the nursing staff, pharmacy staff, cleaning staff, anybody. When you need to, just go and tell them who you are. And I also have told people that even in a patient room, even if you think you’ve been taking care of the patient every day, you should introduce yourself every day to the patient with your name and introduce the team.

I also have said that there is a little bit of stigma in our country with the word “intern,” and I actively try, even myself, to introduce my intern as a junior resident and my senior as a senior resident, because to the general layman, the intern means the one who just brings the donuts and brings the coffee. So there are a few things like that that can help you.

And the other thing I’ve learned is to really give your first name and ask the people. Never call, “Hey, nurse,” “Hey, student,” “Hey, pharmacist.” If you really want to bond a relationship, a long-term one, in the hospital, start knowing people’s names. And even if you forget, I will tell you, it gives you so much mileage when you call somebody, with the nurses. It’s such a beautiful thing to do, and we are all pretty smart, smart enough to remember people’s names. It can help you to bond the relationship. And when you call that same person in the middle of the night and say, “Hey, I’m VJ. Hey, Kevin, how are you? I really need help,” Kevin will never say no to me.

Kevin Pho: One of the things that you mentioned when we first started off was juggling the crystal balls that these new residents are going to have to handle. So I want you to go into more detail: How can these new residents juggle all these crystal balls between their work life, their home life, and their integrity? What are some tips that you can offer to help them?

Vijay Rajput: Yeah, I think lately, whenever I introduce myself to the first medical students, I start with a statement: “I want to make sure that you do not land up in jail in this profession.” And they get all shocked and say, “Really, Dr. Rajput? I’m here to come and have a great career, and you’re telling me not to go to jail?” And then I elaborate, and I say, “Let me give you the story.”

And the most powerful story, which I usually tell them, is of Clayton Christensen, the one who has written a lot on disruptive innovation. When he gave a commencement speech at Harvard Business School, he said, “I’m from the 1972 business student class. How many of my colleagues are in jail right now?” I think this was somewhere around 2004, and he said seven of them are in jail. And that’s exactly, I think, what you should avoid doing, what’s called a marginal cost mistake. And you should do the right thing when nobody’s watching you, right? Those are the two most important things I usually try to convey.

And there are a lot of slippery slopes. There are a lot of places, as physicians, where we see it all the time. We hear it lately in the news. [Remark removed by the editor.] People have gone, physicians have gone, to jail. So there are places where you might lose your opportunity to lose your integrity. So I only said, “Make sure you don’t land up in jail.” That’s the most important thing. That’s the integrity part.

And at the student level, a lot of times it’s the simple lapses, even academic integrity, or managing. I mean, just yesterday, there was a lawsuit in the United States. The student complained that it was a remote exam, and the proctor wanted to see around the room. And, you know, there was a judgment in favor, and it said, “Hey, he’s breaching your privacy.” So the question is, higher education wanted to maintain the integrity of assessment, and that was the reason they wanted to make sure of the student taking it at home, and the students, you know, by breaching the privacy. So these are the fine nuances I really want to make sure of. And the most important thing: Do not breach that integrity, don’t make any marginal cost mistake, and do the right thing when nobody’s watching you.

Kevin Pho: I want to talk about burnout, because that’s a common theme on my site, and it’s affecting not only attending physicians but also medical trainees and medical students as well. What’s your experience with burnout in medical education, and what are some ways that we can help when these occurrences happen?

Vijay Rajput: Burnout is real, but there are a lot of things that have been blamed, and I think lately we are trying to get this juice or mojo from the wrong place. I personally believe you cannot dissipate burnout by going for yoga or doing a mindfulness technique. You need to get out of burnout by being meaningfully engaged in clinical care. The juice has to come by providing good care to your patient. I think the patient gives you that.

So a couple of things I have really lately been talking about. One is curiosity, right? If you cultivate your curiosity, every time in the middle of the night, if you’re a resident and you think, “It doesn’t make sense, what is in front of me, this patient. Let me go one step further,” and you make that brilliant diagnosis, that aha diagnosis, that curiosity will not let you burn up. The meaningful engagement, and that engagement with your patient, is what I was talking about, giving 100 percent in my article, and meaningful engagement with your peers and your staff.

I think we are underestimating the power of that profession. And if you don’t give that power and try to get the power from the profession, you’re going to get burned out. And I don’t think just doing mindfulness and yoga will help. It might help you temporarily.

And the one other thing is, you can prevent burnout, really, with two other things. One is respect. Respect is like air. I have read somewhere that the moment you take out the respect, you will understand. So don’t demand respect; earn the respect. And the one other thing is a part of the work we do: to provide what Amy Edmondson has said very clearly is called psychological safety. We all need to provide that emotional, cultural, and psychological safety to each other, so that it allows us to grow and fully engage. And I really believe you can avoid burnout if you meaningfully engage in patient care or clinical care.

Kevin Pho: We’re talking to Vijay Rajput. He’s an internal medicine physician, and we’re talking about his KevinMD article, “Top 10 things new interns should do.” VJ, what are some of your take-home messages that you want to leave with the KevinMD audience?

Vijay Rajput: The most important for new residents is there is always help. That’s one. The second is it is not all about competency. Learn good judgment from the role models. I think lately we are all talking about competency, but judgment is what’s going to make you a better doctor. That allows you to deviate from evidence-based medicine practice and still do the right thing for the patient in front of you.

And I really believe you need to go the extra mile, and in my mind, the extra mile means something you should do every day which is not in your job description. That’s in my mind, whether that’s as simple as giving a glass of water to the patient when waiting for somebody else to give a glass of water, or anything you do. Go the extra mile. So those are my simple take-home messages: There is always help, and go the extra mile. Do something not in your job description.

Kevin Pho: VJ, thank you so much for sharing your time and insight. Thanks again for being on the show.

Vijay Rajput: Thank you, Kevin, for having me. Have a good day.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes