It has a reputation for a reason. (A review of Intern Year)

And here begins a stream of consciousness of my experiences and emotions as a medicine intern.  Fourth year medical students are tirelessly forewarned of the challenges of intern year, but just as we heeded the advice regarding year one of medical school, it’s not truly understood until you experience it.  

As a disclaimer, I had the absolute perfect setup to survive/thrive throughout intern year.  One of the reasons I absolutely love my program is that our residents are here from around the world (literally- from Venezuela, Thailand, The Philippines, Greece, Mexico, Brazil, Ecuador, India, Pakistan, Jordan, Georgia, Indonesia, England, Nigeria.. not to mention those with hometowns scattered across the U.S.) I can’t imagine having to get used to living in a new country, with a different medical system, without an immediate family support near you..having to work upwards of 80 hours a week at a very high intensity. Some of my co-residents have children depending on them, or spouses working equally long hours in their respective residencies. Being from the U.S. and having rotated in my hospital before starting intern year I was fairly familiar with the system + with no kids and a husband with job flexibility.. I should be the last to struggle or complain. 

The truth is, intern year is intrinsically challenging and it is all relative to your life circumstances.  But on the other hand I can truly say this was the most rewarding year of my life filled with leaps of personal growth. I’ve gathered a list of the extreme highs and lows in hopes that this may resonate with upcoming interns, and provide insight for those not in the field of medicine regarding exactly what we experience. 

1.  ON MAKING MISTAKES

I was in MICU in August, having been a “doctor” for basically a month.  Having not much experience with phlebotomy as a medical student I was getting really excited that obtaining ABGs (arterial blood gas.. basically drawing blood from an artery) was becoming much easier for me.  There was an agitated and intubated patient requiring soft wrist restraints, not well sedated, but needed an ABG to assess if her ventilator settings needed to be changed. I happily went into the room, undid one of her restraints, and collected the blood from an artery in her wrist.  I walked away to take the blood around the corner to the lab. I then returned to a scene that made my heart and stomach flip flop and then sink. The patient had self-extubated (because I didn’t re-attach her wrist restraint) and was in significant respiratory distress.  If not for a nurse walking me through exactly how to remedy the situation, I’m pretty sure the whole experience would have broken me permanently.  We called the anesthesia team who was immediately able to re-intubate her and we set her back up on the ventilator.  I called my senior resident and ICU fellow to explain what happened, and both were so forgiving.  There were no adverse outcomes to the patient, but it could have been worse if not for such a great support system.  

I share this story even though it’s embarrassing because it’s important to know that these mistakes can and will happen.  It reminds me to be so incredibly humble, to be increasingly vigilant of all my steps in patient care, and to be forgiving of the new interns if a similar situation arises.  I also had to learn how to brush it off after a while, to not let the small mistakes in my daily work consume me. Things will arise in the more minute details that can potentially be more devastating to the patient- problems in medication lists when discharging a patient,  orders missed when admitting that could potentially change their management, missed follow up on surveillance imaging in the clinic, etc. etc. It’s crucial to remember that residency, despite making very important clinical decisions, is still a training program.  We are not expected to be perfect but we are absolutely be expected to do our sincerest best.  The well-being of strangers is IN OUR HANDS and this should not be taken lightly. If your mistakes are honest and unintentional, learn from them, take a deep breath, and move on as a more experienced doctor.

2. on being TIRED.

If you read many of my social media posts, it’s pretty obvious I’m obsessed with sleep and sleep hygiene. I would actually pick sleep over anything and I have the luxury of being able to PASS OUT under any circumstances- middle of the morning after a night shift, or curled up on a chair in the resident lounge, or while my husband is downstairs vacuuming the living room .. I’m OUT.  I choose sleep over everything else; I’ll skip workouts, leave home maintenance stuff incomplete, all for the sake of those Zzzzzz’s. Despite all this I was still incredibly sleepy this year!

Your schedule will be more erratic than ever before. In a single week or month you hardly every get home near the same time consistently, and there’s a constant switch from working days to nights with some cross-cover shifts thrown in the mix.  Every time I switch shifts, it takes up to a week to really feel normalized again. Imagine constantly experiencing a feeling of jet lag but instead of having been on vacation you were working really really hard being pushed to your mental/physical/emotional limits. Yeah, that’s intern year.  The only thing I didn’t skip for extra sleep was social events.  In my opinion these years are already priceless- your co-residents become family and despite basically living with them in the hospital it’s one of the greatest pleasures to sit down to a nice dinner, or latin dance, or barbecue with these fine people outside of your little medical bubble.  That’s totally worth missing a few hours of sleep :-) 

3. You will learn SO MUCH. 

In the beginning and even half way through it might not feel like it, but if you take the time to reflect back and compare yourself to the "you" on July 1st.. holy hell it’s amazing. In the beginning I was certain about nothing. I was nervous about putting in benadryl for a stable patient while on night float, let alone treating a simple case of COPD exacerbation or adjusting an insulin regimen.  Because as you move further through the year you still have SO many questions/uncertainties/feelings of inadequacy, it’s difficult to look back and see how far you’ve come.  There’s also very little time for independent reading, so if you’re squeezing it in while at work or for a few hours on a day off it never feels like enough.  But in reality, after the year is said and done, you are much more capable than how you see yourself. I promise!

I’ll also add that you learn so much from your patients, especially if you’re working in a socioeconomically depressed area (as many teaching hospitals are.) If you have the time to truly listen to stories from your patients, you’ll be blown away by their experiences.  How wonderful a job we have, to care for people in their most vulnerable state (sick, half naked in a gown, and probably hungry) who entrust in us so much of the intimate details of their lives.  “Gun shot wound s/p exploratory laparotomy” is just as common on a patient’s past medical history as “aortic stenosis s/p AVR.” On those lighter days and easier rotations, sit down and just LISTEN. There is so much more to learn than medicine. 

4. On being very, very upset.

I’m not talking about in a single instance if something doesn’t go your way. I’m talking about the way-too-common occurrence of intern depression, or burnout, or angst. This is chronic and really hard to get through. It affects everyone differently, or not at all. There is nothing normal about burnout and it shouldn't be "expected" to happen, but the reality is, residency training intensity will lead to it, undeniably.  I can personally say it hit me very fast and very hard, and took a lot of humility to move past it.  Usually happening in the winter months, there’s a very obvious decrease in resident morale.  The excitement has worn off, you’re less afraid, but feel incredibly overworked and under-appreciated. The amount you’re expected to accomplish in a day is astronomical, you’ll look back on a single on-call day and truly wonder how the hell anything/everything got done.  You’ll start to feel a little disconnected from your patients, knowing if you spend too much time with them it’ll put you behind on your endless to-do list waiting for you outside the door.  You’ll feel unaccomplished, confused as to what you’re doing is making a difference, and question how you want your career to be (or in the extreme, if you even want to do medicine at all.) 

For internal medicine residents I think the above feelings are even a little stronger as we try to couple being a stellar doctor with preparing for future fellowship aspirations versus careers in primary care/hospitalist. There’s a pressure to (on top of EVERYTHING ELSE YOU’RE EXPECTED TO DO AND DO WELL) to also do research and show an interest in your subspecialty. On your little time off you may feel this incredible guilt between enjoying your life and heightening your CV for the next career step.  If you’re anything like me, you’ll hit a breaking point. You can’t possibly do it all and still feel human.  Every little negative interaction with a patient, or bump in progress of my proposed research project or minor disagreement with my husband would leave me in tears.  

I was too scared/embarrassed to confide in my co-interns and chiefs that I was struggling. I didn’t want to be known as the complainer or the weak one.  I had this absurd expectation that I had no limitations and that everything could be done while keeping a smile on my face.  Eventually, however, I had to break.  I had to let go of “doing it all” and find enjoyment again in my every day life. I started speaking openly about what I was feeling and no surprise, so many other co-residents felt THE SAME WAY. I felt like starting a movement (which a few months later here I am, helping to initiate a resident wellness curriculum!)   I talked to a few chiefs who coached me through their own experiences with the same angst. It’s incredible how great you can feel simply by saying “I’m super struggling” out loud.  I started being myself again and really re-evaluated what I enjoyed and what I wanted to do as a doctor.  While still not fully confident my career plans will work out as I plan, and I’m a little nervous about trying anything with ambiguity, I can assure you it’ll only happen if it 1) brings me joy 2) is doable while still feeling like an actual person 3) has everything to do with prevention and wellbeing. My advice: don’t forget that you’re a human being, and that you are NOT alone in residency. Ever.

5. On having SO MUCH FUN.

This one is probably the hardest to believe (especially after reading #4) but believe it!  Imagine living in college dorms again, where everyone was friends and there were so many interesting people to meet and talk to all day. This is kind of what intern year feels like even when you’re working incredibly hard.  You are constantly interacting with huge teams- co-residents, med students, pharmacists, nurses, etc.  You work long long hours with familiar faces and seriously funny things happen all day.  You get to know the details of others’ personalities and develop such a serious compassion for all types of people.  

There will be potlucks and lunches and birthday celebrations on a call day.  Nights out too late and the rare opportunity for a summer picnic. Popping bottles of  Martinelli’s on night float during New Year’s. Precious vacation weeks to give your mom and dad a hug or explore another continent, then coming back to your “dorm room” to make it through another service still smiling on the other side.  

The year is what you make of it – it remains ugly and will consume you if you allow it, or transform you into your best self, whichever you prefer.  Do your best to stay true, learn all you can, and prepare yourself– 2nd year (with all it’s own anxiety provoking entities) will be here with the snap of the fingers. <3

All my love,

Shanny, D.O.