American College of Physicians: Internal Medicine — Doctors for Adults ®

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Year-two skills are forged from year-one lessons

From the October ACP Internist, copyright 2013 by the American College of Physicians

By Joshua M. Liao, MD, ACP Resident/Fellow Member

One balmy summer night four months ago, I walked home from work as I had done countless times during intern year. As usual, I prepared some food, leafed through a few journals, and logged on for a wonderful webcam date with my significant other before going to bed. When I awoke, things felt normal ... until I went to wash up. Looking into the mirror, I felt a strange blend of distance and urgency. The face staring back at me, without any buildup or suspense, had somehow changed. It was no longer the face of an intern. I’d become a resident.

According to some, the intern-to-junior-resident transition is the toughest one in medical education. I’ll withhold final judgment until I finish my training, but even just months in, I can affirm that this sentiment isn’t unfounded.

Dr. Liao

Dr. Liao



On multiple levels, the work has been drastically different. Instead of making check boxes and checking details for passoff, I’m now responsible for the few crucial, big-picture items that must be done for each patient. Instead of deciding when to touch base with superiors to cross-check my work, I’m the one waiting to run lists and hear updates. Instead of being paged about everything from low potassium to insufficient bowel regimens to incorrect orders, I just don’t really get paged anymore. And instead of simply making sure I complete my own tasks, I’m responsible for ensuring that all my interns and students complete theirs.

The task of running a team and leading younger learners is probably the most challenging, and most foreign, piece to all of this. Now that I no longer need to write notes, pre-round, or present patients on rounds—now that I’ve essentially been released from the core tasks that defined the last three to four years of my training—I find myself with more time, less direction, and the new prospect of leading and managing people.

Though much less intense, my medical school clinical clerkships did in fact prepare me to be an intern. In fact, one of the best compliments a student can get is that he or she “operates like an intern.” But some of skills needed to excel as a junior resident? Most of us are probably never directly prepared for them beforehand. Very few of us were explicitly taught time and people management in medical school. Most of us had limited practice identifying and engaging others’ weaknesses and strengths in team settings.

Add in the challenges of unlearning our own intern impulses and balancing the opinions and needs of attending physicians, all while continuing to learn clinical medicine, and the intern-to-junior-resident transition really does begin to feel like it’s the toughest that we make.

But somehow, thankfully, most of us get through it. We work hard to fulfill our new roles, like we did at earlier stages of training. We lean on each other for insight. We remember and emulate our role models. We find support in our loved ones. And we learn what it feels like to call up knowledge and experience in a moment of need, things that we learned as interns but never fully realized we knew until we needed them as residents.

This last point, that some of the most helpful resident skills arise from intern habits, is crucial. At first glance, internship appears too busy and hectic a time for much leadership training; there are challenging days when interns must fight just to keep their heads above water. But the reality is that interns are exposed to many small leadership moments over the course of 12 months. Each time they present patients, they have opportunities to commit to big-picture actions that will develop their management styles. Each time they plan their daily workflows, they have chances to prioritize, organize and delegate tasks to students, support staff and even their residents. Each opportunity for team feedback can become a chance to better assess and act on others’ strengths and weaknesses.

But perhaps not surprisingly, many won’t be able do this on their own. To build the habits that will serve them best as junior residents, our interns will likely need our help, as I needed my residents’. Perhaps our biggest contribution as team leaders, then, is to ensure that they don’t get to the end of year one without thinking about skills they need for year two, to instead produce lessons they can practice early, intentionally and with increasing success.

Individual experiences with this will undoubtedly vary. But if mine thus far is any indication, every resident has an important role in building these qualities in his or her interns early.

I’ve advised my interns to set their own concrete goals before each rotation. This can be difficult early on in the academic year when interns are learning the basic ins and outs of clinical care, such as how to place orders, what form of magnesium is on formulary, or where the radiology suite is. But I’ve found it helpful to ask my interns to set a few concrete goals they want to achieve by the end of each rotation (such as learning the current data about venous thromboembolism treatment, leading a family meeting, or teaching one topic to the rotating medical students).

Clinical variety and busyness often make it difficult to achieve every goal. But the main point is for residents to reflect on personal strengths and weaknesses, and create goals that refine the former and bolster the latter. Over time, this produces more accurate assessments and more effective improvements, both for themselves and their own future interns.

The reality with graduate medical education in the era of work-hour restrictions is that we all need to find ways to buttress quality of patient contact as quantity decreases. One practical way to do this is to ensure trainees maximize each encounter, so I always encourage my interns to swing for the fences with their plans.

This isn’t always easy, because most medical students are often implicitly taught to avoid being wrong, thinking that it adversely affects their evaluations. When this posture carries over excessively into internship, however, it can cause new doctors to defer their plans to others and miss opportunities to create their own styles of thinking, which is a near-fatal quality once they become junior residents. The opposite practice can accelerate clinical maturity and lead to interns who are well ahead of the curve in terms of becoming residents.

It’s been said that the best teachers don’t teach information, but ways of thinking. Nowhere is that truer than in this transition, when many of us realize that the most important of our year-two skills were forged long ago, in the practices and habits of year one.

Joshua M. Liao, MD, is an ACP Resident/Fellow Member, the Northeastern Region representative on the ACP Council for Resident/Fellow Members, and an internal medicine resident at Brigham and Women’s Hospital in Boston. Find him on Twitter (@JoshuaLiaoMD) or his website.

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