Resident Expert: My First Year in Medicine

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Interns reflect on their first year in emergency medicine.

If becoming an attending is the physician equivalent of adulthood, then intern year is the coming-of-age. When Emergency Physicians Monthly asked interns about their first year of training, they described a year full of firsts. First resuscitations, first saves, first losses, and first realizations of the complicated maze of emergency care. They also shared initial insights into what kind of emergency physicians they would become, what aspects of EM they enjoyed more than they expected to, and what they found  most challenging.

The most universal theme, however, was not what they did or how they did it, but with whom by their side. Residency typically means leaving family, both relatives and a medical school ‘family’—none of whom may grasp the challenges, rigorous pace, and emotional toll of residency better than fellow classmates.. The interns we spoke with emphasized how the camaraderie and support of each other and faculty carried them through a year of so many firsts.

Some had a long journey before they even began intern year. “You have to develop new relationships, change your wardrobe according the temperature, discover new places for coffee/food, and immerse yourself in the culture,” said Jerry Tavornwattana, who traveled over 1,000 miles from Detroit to Jacksonville, Florida for his internship. Kennen Lee moved from Michigan to Texas.  “I was married shortly before moving, so my wife has been a huge reason why the transition has been so smooth,” he said.

Forging Bonds
Interns described their initial orientation month as an opportunity to focus on creating a bond with their class. Brittany Philpot said her group nicknamed the first month “friendship month” because it did a great job of setting them up to be friends, with a wilderness race, frequent barbeques, and a weekly get together. “We are the most cohesive group our residency has had so far,” she said.

“Our first month included a light clinical schedule that gave us time to have lunch all together and really become a cohesive group,” added Jeffrey Brown.

While some began residency already knowing people from medical school,  others started from scratch. Aaron Deeds came from out of town and didn’t have fellow classmates he already knew, so he was happy that they were  “really open with each other” and some even lived in the same apartment complex. 

Brown described how physical proximity lent itself to strengthening professional bonds. “The ED layout allowed us to have a lot of discussion while we worked. There is a central ‘donut,’ and we are all sitting together in the same place with two attendings present at all times with three to six residents. We could observe their inter-professional management with consultants and listen to them receiving transfer calls. During slower periods, we all talked about life outside the ED.”

For Philpot, starting a family of her own during intern year was met with overwhelming support. “I had no idea how much my attendings would care about me both personally and professionally,” she said. “When I was pregnant, they were genuinely excited for me.” Several of the female attendings took her under their wing, giving her hand-me-down baby items and making sure she had access to a pumping room and time to pump during her shifts.

As the year progressed and responsibilities increased, interns didn’t neglect their class bond. “We decided that whoever is on anesthesia on a given month has to plan a social event,” said Dalton Nelsen. “We had pool parties and ugly sweater parties.”

They also supported each other to make time for family back home. “One of my classmates covered my back up call so that I could travel out of town and see my family,” recalled Deeds. They were also there for each other when classmates needed support for themselves. Nelsen added, “We have helped each other through break-ups, and once one of my classmates even took one of his few days off to take me to the emergency room when I needed to care for myself.”

Interns also had plenty to say about the bonds they developed with their attendings. “They all want to be there and want to teach,” Nelsen said. “They are so smart and have so much to offer. They want to build you up and back you up,” Philpot added.

Nelsen recalls changes noticeable as fast as patients’ condition changes during a single ED visit. “I could see a change in my relationships with attendings even within a month; by the end of the month they trusted you more.”

Lessons Learned
The lessons they will pass on are the ones that stood out from their intern year. For Deeds, learning the variable practice styles was a welcome challenge. “People in a strictly academic setting in a large academic center manage patients differently than how community physicians handle things on their own, and I appreciated seeing the difference.”

Jen Rabjohns was reassured by a work environment where questions were welcomed. “I had a misconception that I had to know a lot already. It felt like a safe environment because I was so comfortable going to my attendings with questions and they were really supportive.”  Kennen Lee echoed a similar sentiment. “I knew there was so much to learn, and I had fear that a lack of knowledge would potentially impact a patient’s care.”

Audiovisual podcasts and online resources were the preferable learning formats for current residents, offering “interaction and feedback lacking from reading textbooks alone,” said Lee.

The interns had plenty of experiences that won’t easily be forgotten. Philpot remembers “being on the front line of women’s health with sexual assault, domestic violence, and miscarriage patients.”   “In my first month I took care of a critical patient and got to intubate them. My attending let me have the reigns and think through all the moving parts of supplies, medications, and differential,” Deeds said. “It was the first time I really felt like I saved someone.”

The doctors look forward to passing newfound wisdom to incoming interns as PGY-2 residents. Recalling senior residents pulling him aside and giving away procedures,  Deeds plans to “pay it forward with procedures.” Philpot said she will remind them to “be nice to consultants and let them see you work hard on your off-service months. She also advises, “Look at the whole patient. Don’t assume that if you didn’t hear about something, that it’s normal. Don’t rely on other people to alert you to abnormalities.”

“It’s okay to be uncomfortable,” says Nelsen. “If you’re not seeing cases that make you uncomfortable, you are not pushing yourself enough.”

Philpot advised being careful about drawing quick conclusions from test results. “You look at so many EKGs and labs during your shift, I would assume if I hadn’t seen it, it must have been normal,” she said. “Don’t assume that if you don’t see or notice a result, that it’s all normal.”

Some compared the practical experiences they received to the structured format of lectures and exams in medical school.  “In residency you learn along the way even though you may not realize it,” said Brown. “I show up every day and try to give patients the best care I can and know that I am learning even if it’s in a different form.”

“It was eye opening to see all the behind-the-scenes work that your attending took care of when you were a medical student. Referrals to social work and consultants, communication with nursing staff, things that just seemed to happen as a med student but that you are responsible for doing as an intern,” said Nelsen. “You’re thinking ‘OK I got this.’ then ‘OK wait, I don’t have it.’ ”

Kennen Lee was most excited about finally taking ownership of patients. “There is still something lacking when what you do for patients isn’t official. Having to see them yourself, write the notes, order potentially life-saving medications, and determine a diagnosis is part of a continuum of care that just wasn’t possible in medical school.”

Increased responsibilities were on everyone’s minds. Deeds was surprised by how much work it would be just to get oriented:  knowing where things are, getting familiar with the paging system, knowing who to call, etc.  Brown noted “My duty and responsibility would weigh more heavily on outcomes than as a student.”

Jerry Tavornwattana said his intern year  was a culmination of finally reaping the rewards of years of formal education. “I looked forward to finally focusing and honing in on what I want to do for the rest of my life.”

Looking Ahead
For many, a lifetime of treating patients looks a bit different than it did prior to first year.

“I didn’t realize how important it would be for me to be available emotionally for my patients’ families,” said Philpot. “Having spent time in EDs myself as a child with ill family members, being a source of comfort as the physician was so gratifying.” She was also taken aback by her passion for coordinating follow up care. “I expected to hate patient education, but it was really fulfilling helping patients figure out their ‘medical home’, where to go first with their healthcare issue by setting them up with a primary care provider and making follow up calls.”

Armed with the experience and wisdom of intern year, the new doctors look to their PGY-2 year with increased goals and expectations. Nelsen plans to “Read more, do more central lines and art lines, and see more patients I am uncomfortable with.”  Brown will focus on “being aware of the flow of the department as a whole” as he manages traumas and sees more patients per hour “without sacrificing quality time with them individually.”

Deeds will be working on improving his overall efficiency, wanting to be able to handle the documentation load better and charting more efficiently during and after his shift so he isn’t staying so late. Plus, he hopes to do more ortho reductions, chest tubes, and IJ lines.

Rabjohns looks forward to finding her niche in EM. “It’s a very academic environment, and there are so many opportunities to explore like aerospace and disaster medicine, ultrasound, EMS, and toxicology.”

An intern may have to move across the country from their families in order to finally begin the practice of medicine.  Yet the new ‘family’ they create will share a unique understanding of their training that no one else could comprehend no matter how near or far. Interns cared for patients and each other, strengthening their skills and adaptability in and outside of the ED. As PGY-2 residents, they are eager to impart their newfound wisdom and welcome the newest family members in the incoming class.

ABOUT THE AUTHORS

Dr. Mahapatra is an emergency medicine instructor at the University of Nebraska Medical Center.

SUB-EDITOR
Dr. Lacocque is an emergency medicine resident at Midwestern University in Chicago and serves as the EMS Section Editor for EM Resident Magazine, EMRA’s official publication.

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