On the Start of Internship

It was over a dinner of Thai food that I finally opened up. One of my most accomplished colleagues in residency had complimented me on my clinical knowledge a couple of times during the meal. Sick of feeling like a charlatan, I told him about the trouble I was having with collecting clinical data and presenting it in an organized way on rounds. I confessed that I did not think I belonged in the program. He listened thoughtfully, and then uttered the three most beautiful words I had ever heard: “Dude, me too!”

-Pranay Sinha, Yale Internal Medicine Intern 2014-15, From The New York Times

Hi everyone:

An intern’s first task is an act of faith.

Thirty-four years ago, on my first night of internship, I was assigned to the BMT floor. It was quiet. There were no admissions, no calls, and no one was crashing. I spent most of the night in the call room, occasionally wandering onto the floor to see if I was needed. It was the quietest night of my residency.

Sometimes it’s good to have time to think, but sometimes it’s dangerous, especially if you’re prone to imagination, which I am. On that night, I was in rare form. Alone with my thoughts, I imagined the questions that would expose my ignorance, procedures that would divulge my ineptitude, and crises that would render me inert. I shut my eyes but couldn’t shut out visions of failure, which were impervious to reason.

Thankfully, I soon learned I was not alone. Most new interns feel like imposters. That’s how it’s always been, which is the reason to call upon faith, because before you know it, you’ll become a different person, entering orders, responding to emergencies, and speaking with authority. It just takes time.

Tuesday June 21 is the first day of internship. Our expectations for those of you starting this week are simple: show up, work hard, ask questions. Look out for each other. Absorb the wisdom of those around you, especially the nurses, pharmacists, and therapists. And be kind: You may not know how to order Tylenol, but you do know how to hold a patient’s hand.

If you doubt yourselves, please know you are not alone. You each belong here, just like the generations of interns who started last June, the June before that, or countless Junes before that. Have faith. You’re going to be great.

Happy Father’s Day and Happy Juneteenth to all. Heide and the girls are cooking up a storm for the celebration.

Mark

PS: This morning, a record 64 members of our community—residents, former residents, and faculty—share words of wisdom for our new interns. Some finished their internships decades ago; others have two days left. All are experts: they are the physician-teachers who will walk beside you, your guides through the exciting year ahead:

• Be committed to learn each patient’s personal story. The rest will follow.
  • Vincent Quagliarello, Infectious Diseases, Vice Chair for Education and Academic Affairs (and former Chief Resident)
• Prioritize sleep! Getting sufficient sleep is important for memory, performance, mood, and maintaining a healthy weight.
  • Lauren Tobias, Pulmonary Critical Care and Sleep Medicine (and former Chief Resident)
• Never worry alone! It’s always ok to ask for help.
  • Clare Lambert, Neurology resident
• Welcome!! This year will likely be the steepest learning curve you will ever experience as a physician. Even if you don’t feel that happening day to day, it will be very clear to you the first day you are a 2^nd year resident and have brand new interns! Enjoy the learning and remember all our doors are open anytime you want to have a cup of coffee or chat.
  • Lynn Tanoue, Pulmonary Critical Care and Sleep Medicine, Vice Chair for Clinical Affairs (and former Chief Resident)
• Treat every day as an opportunity to learn and make a positive impact upon yourself, your co-residents, and your patients. Also, a big part of intern year is becoming efficient, and your seniors are here to help! Most days you'll be actively working from the time you come to the hospital until you leave, but intern year will fly by. I promise, you'll look back in a year and be surprised at how much you've grown.
  • Dan Kats, PGY2
• Don’t be afraid to ask for help! No one will fault you for not knowing something. After all, we all embark on this journey called residency to learn :)
  • Sabrina Ngong, recent graduate, Hospitalist Johns Hopkins
• Your time off is sacred - plan ahead by scheduling fun things to do or “treat yo’self” activities like a dinner with friends, a spa date, or a day hike. Outsource your chores when possible so you can maximize your free time - like hiring the occasional house cleaner or dog walker (ask co-residents for referrals). The tired post-call future you will thank you for it. Find a senior resident that you admire and seems like they know what they’re doing – emulate their style until you figure out yours. It’ll get easier. Always bring extra snacks and food to the VA, particularly on the weekends (the cafeteria will be closed). Prioritize learning ultrasound guided peripheral IV placements, especially if you have a night rotation earlier in the year. There will always be a patient who needs empiric IV antibiotics at 2am.
  • Ysabel Ilagan-Ying, PGY3
• There will be such a strong urge to keep weekends open, but I encourage you to plan as many little trips as possible. These trips can be as simple as a hike in the woods, a bike ride, or a day at the beach. Just give yourself little things to look forward to! This advice was given to me by a fellow intern this year, and I hope to be more intentional about it in the coming year! I wish I had realized it sooner!
  • Michael Arcieri, PGY2
• Always know there are so many people there to help and support you - reach out frequently and openly; we are here for you. Remember that we were all in your shoes at some point!
  • Kimberly Glerum, PGY3
• Take it one day at a time. Use each day as a learning opportunity; and remember, we’ve got your backs.
  • Lou Levine, PGY3
• Ask questions if you are uncertain. Share when things go wrong- it is easier to solve things together. Be kind to yourself.
  • Scott Sussman, Hospital Medicine and Palliative Care
• Treat every patient as if they are your mother, father, sister or brother. If you are ever in doubt, that sentiment will guide you to the right path. At the same time, treat yourself as you would a loved one and take care of your health and happiness. Reach out for help when you need it, we are here for you.
  • Vandana Khungar, Digestive Diseases, Interim Associate Chair for DEI
• Ask for help instead of struggling on your own. If you feel lost or overwhelmed, know that you are not alone and we (your designated peer mentor, rotation seniors, or random seniors you see in the halls) are all here to help you! Do non-medical things when you're off. Maybe even make plans... to do absolutely nothing.
  • Anna Qian, PGY3
• Don't worry all by yourself. If a patient seems to be getting sicker, if something about a plan seems off, or if you have a gut feeling that something is about to go wrong, tell someone. Either they can reassure you (in which case you'll learn!) or they'll also be worried, and you'll have the help you need in doing the next right thing for the patient.
  • Meg Grammatico, PGY2
• Be patient with yourself as you take on this role. Forgive yourself for any mistakes and embrace the learning curve. You will always have support here!
  • Julia Joseph, PGY2
• When in doubt, go see the patient. It’s always ok to ask for help! The days can be long but the years are short, so make sure you have a life outside the hospital. Before long, you’ll be at the end of the year and surprised at how much you’ve learned and grew!
  • Cate Wright, recent graduate, Cardiology fellow
• Sometimes telling patients “I’m not sure” is the best thing to say to your patient. Take the extra second to learn a fact about your patient every day. It honestly makes the job so fulfilling in the darkest days. Remember medicine is a team sport! You have so many people to turn to if you ever feel overwhelmed. You got this.
  • Ramya, Kaushik, PGY3
• When you start a new rotation, make sure you ask your resident where the closest bathroom is and where you can fill your water bottle. It’s important to stay hydrated! And keep a running list of the bathroom and supply room codes for future reference :)
  • Hailey Baker, recent graduate, Rheumatology fellow
• Be kind to yourself. Be ready to learn but don't beat yourself up too much for things you don't know. And make sure to pat yourself on the back for the wins- big or small- that will undoubtedly happen along the way. There is a special type of joy you'll find from coming into your own professional identity as a physician. It's one of many reasons why part of me will always miss intern year.
  • Thilan Wijesekera, Hospital Medicine
• Always make sure you address your immediate needs first (eat and use the restroom PRN before approaching a bolus of work)!
  • Matt Grant, Infectious Diseases, Associate Program Director
• Everyone brings something different and helpful to the team from their background and experiences. As a new intern, we are eager to hear your fresh perspective, so do not ever think you have nothing to add because you are new! On the floors, we all work as a team together to get everything done. You do not ever have to feel alone or feel like you have to do everything! We are so excited to have you 🙂
  • Mary White, PGY2
• People will ask you lots of questions you won't (and shouldn't!) know the answers to. Intern year is less about knowing what to do and more about knowing who to ask for help (seniors, nurses, attendings, pharmacy). There will always be questions you don't have answers for, but as the year goes on there will be fewer.
  • Greg Breuer, PGY2
• When you are caring for a patient from one day to the next, look for the responses to the decisions you made. is the blood pressure improved from yesterday? is that in response to a change you decided to make? when things get better for patients, we often forget to reflect on the ways we help good things happen; when things get worse, we often blame ourselves. take time to recognize what you did well, so you can make the same decision again next time.
  • Sharon Ostfeld-Johns, Hospital Medicine
• “THIS TOO SHALL PASS.” When you are under the pressure, know that this is temporary for you and you will see better days. Try to seek help and talk with others about your feeling. I remember a day that we admitted 10 patients at the VA. I found it overwhelming! However, at the same time, I was thinking maybe I am weak! I remember, when one of the chiefs stated that she felt she was dying when she admitted 9 patients in one day, I concluded that I am good! I wish you all the best.
  • Farshid Etaee, PGY3
• Medicine is a team sport. You are never alone in the hospital! Always ask for help if things don't make sense or you feel overwhelmed. Listen to the nurses! They will often sniff out problems before they start. Keep a list of subjects that are your weaknesses, read, and make them a strength. Don't be afraid to ask questions. If you don't know something, your colleagues probably don't know it either and the entire team will benefit from your thoughtfulness.
  • Elliott Miller, Cardiology, Medical Director of CICU
• Read about your patients - this will solidify your knowledge. Socialize with your co-residents - they will be your friends and colleagues for life. Do something fun for yourself each day - this will keep you young at heart.
  • Deborah Proctor, Digestive Diseases, Medical Director, Inflammatory Bowel Disease Program
• Try to strike the right balance between intern tasks (notes, orders, etc) and being at the bedside learning from your patients. Take chances on rounds. Avoid the tendency to defer to residents or attendings so you can feel like you are driving management and learning from your colleagues.
  • Andrew Cox, recent graduate, Primary Care
• The internship year is one of the most exciting and formative in all of medicine. A day in the life of an intern is filled with immeasurable exhilaration, stress, fulfillment, a sense of being overwhelmed, invigorated, and exhausted all at the same time, with many highs and lows. There are days when you feel like a real doctor, providing healing to patients and their families in ways that only you know how… And there are other days when it feels like everyone else is ahead of you, and you don’t quite know what’s going on, and you might even wonder whether you should be doing this at all. All of this is normal, and whatever you may be feeling and experiencing, others are as well, so you should feel supported and empowered to reach out and share your thoughts and perspectives with your colleagues as we've all been through this before and are here to help you through the year. Also, it can be helpful to keep in mind that this is a one-of-a-kind journey, where you will learn, grow, and develop so much, as a doctor and a person, and everything you will experience becomes part of that journey, no matter how great or not great it all feels. As an example, my very worst day of internship was my first day on the BMT service, which was so overwhelming for me that I actually took the next day off and contemplated quitting, then decided to return only at the encouragement of my now-husband, after telling myself that, if I actually finished residency, I would never go into heme/onc ... oh the irony! It’s all part of the journey, and if I was able to do it, you will, too, and you’ll have many wonderful stories and experiences to share with your patients and your colleagues as you learn to become the physician and healer you are destined to be.
  • Alfred Lee, Hematology, Fellowship Director of Hematology-Oncology
• Whatever you are bringing to this year is enough, you are enough! Everyone who will be teaching you started in the exact same place you are starting. Bring your growth mindset!- Drill down on what you want coaching on and ask for feedback early and often. Everyone wants to help!
  • Dana Dunne, Infectious Diseases, Director, Internal Medicine Clerkship and Associate Chair for Education and Academic Affairs
• One of the best pieces of advice I heard in residency is "never worry alone." If you're paged with borderline vital signs, unsure about a medication dose, or concerned about how a patient looks when you preround, it always helps to talk it over with someone. Intern year is a huge adjustment, but everyone around you is willing and happy to help. You belong here, and you're here for a reason; hopefully it's only a matter of time before it feels like home.
  • Ann Soliman, recent graduate, Traditional Chief Resident
• You’ll do great! A former chief told me the most important thing is “try don’t lie” and as long as you do that you’ll succeed! We really don’t expect anything of you day 1 except to show up. We know the beginning of intern year will really be about learning a new system, which can be overwhelming at times. We’ll be there to support you. Don’t underestimate your contribution to the team or the things you’ll teach us. You’re all very caring and motivated physicians and we’re so excited to be part of your journey/growth.
  • Kate Feder, PGY2
• The key to making the most of intern year is to frequently self-reflect on how to maximize the moments that bring you joy (e.g. talking to patients) and how to minimize the moments that don’t (e.g. writing notes).
  • Michael Mankbadi, recent graduate, Hospitalist at Beth Israel-Deaconess Medical Center
• Keep an open mind and ask for help when you need it. You'll all be great!
  • Ben Rodwin, Hospital Medicine, Associate Program Director
• Each of you deserves to be here because you are smart, caring and hardworking. DO NOT FORGET THAT. Training is fun, exhilarating, but sometimes it is overwhelming. You will make mistakes, and sometimes you will wish you did things differently. Lean on your seniors, your faculty, and our amazing leadership. Seek them out, and be kind to yourself. You are amazing, and your patients are lucky to have you.
  • Keval Desai, PGY3
• Be mindful of imposter syndrome. You are meant to be here.
  • Liz Prsic, Oncology and Palliative Care, Co-Chief of Oncology Firm
• Looking back at my own residency experience, I felt that I always put patient care first which translated into always doing all the tasks that interns and residents do but sometimes at the expense of my own learning and at times sacrificed teaching conferences. Don’t shortchange yourself in terms of the teaching and academic conferences- that is your time and be protective of it, and take advantage of it. Obviously if a patient is crashing, that is a difference story, but most of the time that isn’t the case. Sometimes it just takes a reminder as the attending, or case manager, or nursing may not know or forget when your didactics are. Finding that work/life balance is a moving target- there will always be more to know. As one of my mentors said in his last lecture before retirement: “Each and every one of us must choose our own level of ignorance that we are comfortable with”.
  • Jurgen Holleck, Hospitalist
• I just want to pass on the best advice I got before I started as intern: At the end of the day it’s all about the patients and there is no such thing as a meaningless task. Calling families, ordering a patient's food, or even spoon-feeding a patient his/her breakfast is what will make you a great provider. Everything else will come with time.
  • Arsh Khokhar, PGY2
• I have no wisdom to share, but I found this self-challenge to be difficult and rewarding, “Never be the ‘covering provider.’ Always be the physician responsible for patients under your care.” I find the same challenge helpful as an attending physician by simply adding “and accountable” after the word “responsible.” It always realigns my priorities.
  • Ed Manning, PCCSM
• Welcome to the Yale Family. This is an exciting phase of your career to care for others and be cared for, to discover and be discovered for your amazing talents.
  • Charles Dela Cruz, PCCSM, Director of Physician Scientist Training Program
• We didn’t have smartphones back in the day and information was not easy to obtain. Remember, you don’t have to have encyclopedic knowledge- you just need to listen to patients and know when to consult with your smart phone or smart resident.
  • Dan Federman, General Medicine, Chief of Medicine at VA Connecticut Healthcare System
• Intern year has the reputation for being a difficult year. And there’s no question, it is not easy. The mornings are early, the days are long, and the job is hard because the work is consequential. But what I found, perhaps unexpectedly, was that it was also a year of so much else: exponential professional growth, deep camaraderie with my co-interns, and profound experiences caring for patients. So know that it will be an amazing year, know that there are many people here supporting you, and know that you belong and have much to contribute. We are so excited to welcome you!
  • Ilana Richman, General Medicine
• Show up, have a good attitude, be available, and you’ll be fine.
  • Matheus Simonato dos Santos, PGY2
• Be patient with yourself. Even the best physicians and the residents you’ll come to admire the most started as day one interns. Ask questions about things you don’t know (as simple as where is the bathroom or as complicated as what social barriers might be contributing to this particular problem), the more you ask, the more you’ll learn! You deserve to be here (as someone once told me, nobody ends up at Yale by mistake) and the program is a better place because of you. We’re excited to see and help you succeed!!
  • Sofia Cruz, recent graduate, Traditional Chief Resident
• The residency has tough times but also have fun times. What is most important , however, is that your colleagues before you successfully met their career goals and are among the leaders in the field. There is a light at the end of the tunnel that makes the hard work worthy of every effort. Good luck.
  • Arya Mani, Cardiology (and former Chief Resident)
• Listen to the patient first when taking a history. They will guide you to the diagnosis
  • Naseema Merchant, Hospital Medicine
• Spend time with your patients, learn from them and in the process will learn much about yourself. Strive for balance between your personal and professional life, and lean on your co-residents, program leadership, family, and friends when you need support. Residency goes by fast...enjoy it!
  • Michael Fuery, recent graduate, NHPCC Chief Resident
• Everyone is nice, and everyone remembers what it was like to be an intern, so let others be kind to you but also be kind to yourself. Focus on learning, serving, and growing. A little enthusiasm and effort will go a long way!
  • Albert Do, Digestive Diseases
• My motto (which I developed as an R2 and have taught since then) was “Love ‘em and make ‘em naked.” Find something to love about each patient you meet, and make sure to examine every square inch of their body with care and discretion. We all want to feel loved, and we’re all really good at hiding things – especially things we are afraid or ashamed of.
  • Tamar Taddei, Digestive Diseases, Chief of Digestive Diseases at VA Connecticut
• You are rarely on your own during residency. You are a part of a large supportive team that includes your co-residents, chiefs, attendings, consultants, and many others. If you are worried about one of your patients, you should not be worrying alone and seek the help of others. Our work is a team effort.
  • Ali Khan, PGY3
• We believe in YOU. So, BELIEVE in yourself.
  • Steve Baldassarri, PCCSM
• A wise mentor once told me “no one should ever have to worry alone”. Always remember - everything will be ok and there is always someone to help/support you, you are never alone. The learning curve is steep, but you are capable and will surpass your own expectations regularly. You are here because you deserve it, and you have everything you need to succeed. No, you are not the exception and no you did not slip through the cracks. You've got this.
  • Jess Petrov, PGY3
• Never assume, always confirm with your own eyes or ears. Most of the mistakes I have made or observed have happened because of incorrect assumptions
  • Marwan Azar, Infectious Diseases, Fellowship Director of Infectious Diseases
• Believe in yourself! You know that everyone started where you guys are so trust the process and learn from everyone around you, seniors, nurses, and patients. You are going to have some great moments in residency!
  • Shreyak Sharma, PGY3
• It is ok to struggle. No one is perfect. If you are struggling don't be shy. Being vulnerable is powerful. Share your vulnerability with your friends. Excellence comes with time and the best doctors are the most patient one.
  • Hassan Mirbolouk, recent graduate, Cardiology Fellow at Johns Hopkins
• Have fun. Make mistakes. Do your best. What else is there to do?
  • Brandon Lee, recent graduate, ID Fellow
• Do your best and enjoy the journey! Finally, you are doing what you've worked so hard to be able to do all these years! Trust in the process that has produced such exceptional residents, fellows, and attendings. If they could do it, so can you!
  • Wafa Nabi, PGY2
• Never hesitate to ask. We are here for you 24/7
  • Stephanie Halene, Hematology, Chief of Hematology
• We are often our own harshest critics; learn early and often to practice self-forgiveness and self-love. It is natural and understandable to make mistakes, and to not know how to do something often out of just shear ignorance. There’s a lot intern year that feels like it is out of your control. There will be days when things go horribly wrong and you question your ability to do this work, but if you tried your best and did the best you could for your patients given the circumstances, you have nothing to hold your head down on and it’s okay to just survive. You grow so much as a doctor and as a person during these days, when you realize that nothing can break you. Over time you can develop a sense of peace and zen when you learn to accept and let go of what is outside your control; when you realize you can smile and laugh in any circumstance (this is something that patients have taught me). One of my favorite quotes from John Steinbeck is “Now that you don’t have to be perfect, you can be good”. When you are with your patient in their room, take a step back and take a deep breath and appreciate the sanctity of the doctor-patient relationship. Remember the special joy and meaning that comes from connecting with your patients and making them feel at ease with you and earning their trust. You will never lose that human ability to comfort and to heal. It is a privilege to bear witness to humanity in its most vulnerable state. These are the moments that touch and inspire and carry us through.
  • Johnathan Yao, PGY2
• When in doubt, always go to the bedside. Never worry alone, help is always around.
  • Evi Vemmou, PGY2
• “The art of epidemiologic reasoning is to draw sensible conclusions from imperfect data.” George Comstock. “So let’s be kind to one another as we learn to make sense of unfolding and evolving information.” Ditas Villanueva
  • Ditas Villanueva, Infectious Diseases, Chief of Donaldson firm
• It’s ok to say no and prioritize time for yourself!
  • Arjun Watane, recent preliminary intern, ophthalmology resident
• The bad news first – it is more than likely that you are underqualified to be a “doctor” on day one of internship. To some extent, any anxiety you are feeling is at least partly justified. But here’s the very good news, you aren’t expected to be a fully-qualified doctor on day one, you’re expected to be an “intern”. An intern is part of a giant team: attendings, residents, fellows, students, consultants, nurses…the pressure isn’t on you, it should be on the rest of us. If we do our jobs well, you will feel safe, supported and even nurtured while you grow into the role of doctor. So, put down your pepto, get some sleep, eat well, exercise and enjoy the sunshine. We’re here, practicing our teamwork with last year’s interns, watching them be doctors.
  • Chris Ruser, General Medicine, Chief of Primary Care at VA Connecticut
• Get comfortable getting out of your comfort zone. Be curious! When you finally feel like you know what you are doing, rattle the cage of complacency and get back out of your comfort zone. Everything is an opportunity to learn something. Establish a community. Your Program Leadership are your allies and advocates. You are never alone.
  • Cindy McNamara, General Medicine, Associate Program Director
• Congratulations on your great match! Be assured that you have joined a wonderful and supportive family. You will never be alone, and everyone is there to help you. Consider "patient care" as your "highest priority" and try your best to advocate for them and ask for help whenever needed for this purpose. You might be nervous and stressed at the beginning. Don't worry... this is what we all have gone through. As time passes, you will feel much more comfortable and confident and will deeply enjoy your job, practicing medicine, and helping your patients in different aspects. You will be very satisfied with how much you learn and grow during the intern year.
  • Saeed Soleymanjahi, PGY2