Habits of highly effective interns [PODCAST]

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“The clocks have flash forwarded, and here I am supervising incoming interns on the 1st of July (which for the past two years has fallen on a weekend). As a frenetic day has finally come to a close and a walk along a park where the trees have acquired a new color as the sun sets, I cannot help but reflect on my initial days of internship.  I am glad for all the initial lessons, but I wish I had a head start to ensure a great initiation rather than relying on serendipity.”

Sam Kant is a nephrologist.

He shares his story and discusses his KevinMD article, “7 habits of highly effective interns.”

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Transcript

Kevin Pho: 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/podcast.

Today on the show, Sam Kant. He’s a nephrologist, and we’re going to talk about his KevinMD article, “7 habits of highly effective interns.” Sam, welcome to the show.

Sam Kant: Thank you. Thanks for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Sam Kant: I trained on both sides of the pond, in Ireland and the U.S. I did my internal medicine residency and was chief resident here at University of Maryland. Then I spent three years at Hopkins doing fellowships in general nephrology and transplant. I’m now a transplant nephrologist at Hopkins, in my first year as an attending, enjoying life as it comes.

Kevin Pho: Excellent. So tell me about that transition from being a fellow to attending. What’s something that surprised you during that transition?

Sam Kant: I think the biggest thing is the knowledge part. It comes as we go on, because there will be times that you will be caught out saying, “I don’t know this.” I think it’s important to approach senior attendings to ask them. I don’t think there should be any, quote-unquote, shame in asking because, “Oh, I’m an attending. I don’t think I can go and ask a senior attending about this.” I think it’s very important to seek consensus. I’ve noticed even the most senior people asking for consensus around them, from the people who might not have trained as long as they have.

With management quandaries in transplant, there are so many unknowns: How do you treat a certain ailment? There might not be a randomized controlled trial or a lot of studies to support a certain treatment, but experience is also an important form of evidence, I feel. In the end, if someone’s been in the field for a long period, it really helps to ask them about that. There will be things that will be out of the norm. They won’t follow a guideline or an answer in a textbook. So I think these are the ones in which you always have to think about going and approaching someone who knows it. Their experience is like evidence to you.

Kevin Pho: All right. So speaking of transitions, one of the biggest, of course, is going from medical student to intern, and in your KevinMD article, you talk about seven habits of highly effective interns. So for those of you who get a chance to read your article, this was published a few years ago. Just walk my audience through it. Share the story of why you decided to write it.

Sam Kant: So I think one of the things that always bothered me is that the transition from being a student to an intern is actually a very big leap. You think that you’re very prepared going into it, but you’re not really, because on the first day of internship, I really felt, “Oh my God, I don’t think I’m ready for this.” Of course, medical schools go through multiple courses and everything, but courses don’t bring you down to actual battlefield experience. I hate to use that analogy, but I think it’s pretty befitting. You get there and you’re like, “Oh my God, I’ve seen all these simulations, and I’ve seen what to do.” But when it’s a real person in front of you that you’re actually responsible for, I did feel, you know, I’ve been prepared.

And that’s what led me to think. When I was a chief resident, I was preparing slides for incoming interns on how to go through their year. As I was doing those slides, I said, “OK, why don’t I just do it as seven habits?” I’m a big fan of Stephen Covey. I think he did a very good book, and yes, I used a part of that title because it’s befitting. There are habits, and I know there are many more habits other than the seven that I wrote. But at the time, looking back in my rearview mirror, I think it was very important to think about them, and there turned out to be seven habits.

I think the biggest one I would say, when you’re going into intern year, is have a process for doing things, whether it’s approaching the electronic health record or even approaching a patient. Have a certain process: How are you going to amalgamate all the plethora of information you have? These habits will not happen by serendipity. You’ll have to work on them, right? I think we have this perception that, “I’ll develop this as time goes on.” I think it calls for a lot of active work, conforming, as you form habits of your own in your personal life; that’s also in your professional life. And this is the foundation, your intern year, because then you’re supervising other interns. So set it up now. Have an idea of what you’re going to do, and be very deliberate about it.

Kevin Pho: So let’s talk about that first one, have a process. Give us a scenario or case study of that principle in action.

Sam Kant: For example, you’re certainly transitioning to a new electronic health record. You may have worked on it because you’re continuing your residency at the medical school that you went to, but still, I noticed we’re not taught enough how to amalgamate that information. Say, for example, you’re going through a chart. I noticed a lot of times interns go straight to labs. Very important, you want to do labs and everything, but I think there’s a process of getting to those things. Why don’t you first look at their vitals? A lot of times, you’ll be talking, presenting, and you’ll be like, “So why are they tachycardic?” It’s hard to go through all those things suddenly, and you’re like, “Oh, I forgot to look at the vitals.”

You want to go through vitals, look through the notes from overnight, and see if there are consult notes that have been put in, even nursing notes. A lot of times, if there’s a one-liner from a nurse, that’s golden, even better than a consult note a lot of times. Then you go through their medications, slash, medication administration record. Overnight, they got a medication that led them to be confused, and a lot of times, it wasn’t passed on in the handover.

And lastly, I would go to labs and then look at that. I think it’s important to keep consistently looking at things with the process, so you don’t miss anything. I know it sounds dogmatic. Unfortunately, this is where we are with information overload, and you’ll be happier and more effective in that process.

Kevin Pho: Now, you did mention nurses, and one of the habits was befriend thy nurses. Talk more about that one.

Sam Kant: Absolutely. I think that should be number one, in hindsight. The number of times I’ve been taught by excellent nurses, who’ve also helped me and backed me if I made a mistake or an error, considering that I was new. I just don’t think you can ever state it enough, how important they are to your life and to the medical system. I think they’re probably the most vital part, because they’re on the ground all the time, looking at the patient.

So I would say listen to them. I know you’re trying, as an intern, to establish your autonomy and your authority. You probably have to forget all that when it comes to a nurse coming and telling you, “I’m worried about this patient,” or “I would like this to happen for a patient.” Listen to them. They have eons of experience in comparison to you. I still do this as an attending, believe me. That’s the first thing: If I’m worried about a patient, I go ask the nurse, “Hey, what do you think? What’s going on?” I think it’s very important, and I don’t think it’s taught enough: Please go approach nurses. They’re actually very happy to help you.

Kevin Pho: So for those medical students who may be listening to this, give us an example of the type of questions that physicians may ask nurses that they may not even be aware of regarding the patient.

Sam Kant: Yeah. For example, sometimes when you’re doing handover in the morning, the nurse manager from overnight or nurses might join you. If you’re really concerned about a patient, they’ve tracked the patient from overnight, all throughout. They can actually tell you what happened, how it all started, and how things progressed. Did something help, or did something worsen it? Because as an intern, you’re not going to be there at the bedside all the time, and you’re not going to have that face time, unfortunately. But the nurses will have that timeline for you and will also be able to give you an assessment: “I think this is what’s going on.” It actually gives you a great head start, if you think about it. So I think it’s very important to do that.

Kevin Pho: Now, another one of your habits is time management, and we’ve got to go to this one, because these are medical students we’re talking about. They’ve already graduated medical school. They got into medical school. They presumably already have time management skills. But tell me how time management is different as an intern compared to a student.

Sam Kant: Oh, absolutely. I think the biggest thing is, I would say, you also have to strike a balance between your personal and your professional life. Another thing that I think we keep sacrificing is our personal life in service of this. And I’m not saying you should be a martyr and you should be spending all your time at Costco, because if you’re happy outside of work, you will be at work, and vice versa. So I think these spheres actually coincide rather than being separate.

So how you’re approaching your time in the morning, after you finish your handover or morning report, how you’re approaching things: For example, a patient that needs a lot more of your attention, go to them first. These are examples of time management techniques, rather than going to the most stable ones that could wait before you could see the sicker one.

How you dedicate your time early in the morning: One of the people I look up to, Bob Centor, tweets about it all the time: Call your consults early, so that the consultants are also ready to come see patients. You have a management plan early, and patients get to leave the hospital earlier, because there’s a plan in place and things are set into motion early. So these are the minor examples that I would say really help you with time management, especially.

Kevin Pho: All right. Let’s go to some other habits that we haven’t talked about.

Sam Kant: I think one of the things I would always say is, we get into this rush of complaining a lot. Our seniors complain, so we also complain. Believe me, I’m privy to it too. I’m no saint when it comes to that. But I think the biggest thing that always got to me was in one of the postscripts of Atul Gawande’s books. He said that he was sitting around having lunch with his colleagues, and he noticed everyone was just complaining, and it really makes you not look for a solution to the problem.

Please do, sometimes, when you need a rant. Please go ahead; it will make you feel much better. But if it becomes a constant part of your life, you just don’t realize it actually saps a lot out of you and just makes you more and more helpless. So I think to check on that and keep an eye on that is very important, especially starting off intern year, because again, you’re putting the foundations in.

The other thing I would say, in the interest of time, is that we’re also living in this age where we’re getting pinged every second. The moment we’re in the patient’s room, we’re trying to have a conversation. The patient’s looking forward to seeing you, because it’s an anxious time for them. We look at it as normal happenstance that there’s a patient in the room, but on the other side, there’s a person who’d like to get home, who would like to know what’s wrong with them or what ailment is affecting them. They’d like to know the management plan.

I think it’s important to be there, and I suffered with that. I’d be getting a page from a nurse, getting a page about another patient needing a medication, Tylenol. You want to make sure when you’re there, you’re there. Of course, if someone’s sick, you need to drop everything; please go. But when you’re there in that clinical encounter, I think patients also notice if you’re there, rather than thinking about, “What am I going to do next?” Even if it’s for two minutes, be there. I think your patients will be happy for it, and I believe you will be too, because you’d be like, “I think I gave my best in there.”

Kevin Pho: No, I think that’s a great point, being present for patients. And I think that’s especially more difficult now, because there’s more technology. There are more digital results. There’s the electronic medical record. There’s a computer. So how can new interns balance that bedside care with all the technologies surrounding them and all the attention they have to focus on the computer?

Sam Kant: Yeah, I think it’s just making sure that you’re conscious that you will be getting hit by all these constant ones, but most ones will not be super urgent, and you don’t have to attend to them. When you spend your five, 10, whatever amount of minutes with the patient, you can always leave the room when you’re finished and attend to them quickly.

Also, knowing what is something that needs to be done now and what needs to be done later, I think it’s something that you pick up as time goes by. But I think you already have an idea, right? When you’re a student, you can get a bit of a simulation about, “OK, I don’t need to really prescribe this medication straight away right now,” as opposed to, “Someone’s blood pressure is low and they’re tachycardic. You need to go to them now.” So forming those frameworks, I think, is very important, and realizing, if you are being paged about something important, go attend to it straight away.

Kevin Pho: We’re talking to Sam Kant. He’s a nephrologist, and we’re talking about his KevinMD article, “7 habits of highly effective interns.” Sam, what are some of your take-home messages that you want to leave with the KevinMD audience?

Sam Kant: I would say especially for interns, who I think need the most help at this period when they’re transitioning, make sure, as I mentioned, you’re there with patients when you’re there. I think that will always stand the test of time. They will appreciate you for it.

I think the other thing I would say is, please do not ignore your personal life. If you have to make a phone call to a friend or your family, please do it. It’s almost like, I give the analogy for exercise: Sometimes you don’t feel like going, but you’d be happy you did it. So take the time. If it’s a drive from the hospital back home, call somebody. Talk to people. Do not lose out on it.

I have to say, personally, I’ve lost out on a lot of friends. I lost touch with a lot of friends because of this. Do not do that to yourself. I think you’ll be happier keeping these people around, and they’ll be the ones supporting you throughout your career. I think they’re a very important aspect of your life.

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

Sam Kant: Thanks for having me, Kevin. It’s great. Thank you.

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