Advice for the New Twos

July 08, 2018
by Mark David Siegel

Hi everyone, 

Of the three years of residency, the second is the most challenging, particularly in July.  As an intern, you sign your first orders, you learn to multi-task, and you start to believe it when someone calls you “doctor.”  By August, you’re sailing.  As a PGY3, you’ve completed two years of training.  You’ve led teams, you’ve made life and death decisions, you’ve built a teaching repertoire, you’ve risen to challenges, and you’ve rebounded from mistakes.  You’re confident, mature, and almost relaxed. 

Becoming a PGY2 is a bigger leap.  Now you’re the leader.  Interns, nurses, and patients turn to you for answers.  You run codes.  You intubate some patients and you send others home.  You map out diagnostic and treatment plans and—the biggest challenge—you step back from intern work, negotiating the right balance of autonomy and oversight for your own intern.  

All our PGY2s are ready to soar.  They’re master pre-rounders, presenters, and note writers.  They can find anything on EPIC and know which numbers to call.  They’ve amassed a treasury of useful knowledge.  But no matter how ready they are, nothing fully prepares them for the transition, or that all too common feeling of vertigo that can affect us all when we look down for the first time and realize the safety net is smaller than it used to be.  I remember that feeling well and have come to appreciate the power of practical wisdom to mitigate vertigo.  

No group understands the PGY2 transition better than our new PGY3s, so I decided to tap into their collective wisdom and ask them to share what they wish they’d known a year ago, when they became PGY2s.  Here’s what they said:

  • Lauren Pischel: You have now been freed in some ways from the boulder of documentation. There is more time to learn and think through nuanced clinical decisions. Take these opportunities to learn as much as you can from your subspecialty attending. Do not expect to know everything as a PGY 2, but rather use this time to learn and learn voraciously. Spend more time with sick patients and really try to figure out their underlying pathology. You now have a clinical instinct, so trust it. Don't be afraid to ask for help or run things by your peers, they are there to support you.  Each intern is their own learner, and you will learn their strengths and weaknesses and adjust accordingly. And most importantly, don't forget to eat on 28 hour call!
  • Natalie Uy: You can always ask for help, make the interns look good!
  • Mike Breen:
    • You all are excellent doctors and you have developed some clinical instincts by now.
    • Early in the year, you should probably be double checking most of your interns’ work. You should do this all year for very ill patients.
    • Use the experience of all the team members. If another team member tells you something that does not make sense to you, approach it with respect and curiosity. "I'm not sure that I follow. Could you explain that to me more? What am I missing”
    • It turns out that care coordination rounds are actually critical. Give them your full attention. Ask a 3rd year if you're not sure what to do. Include a dispo section in your thinking; I actually keep my own very basic notes for each patient.  "Return to Elim Park STR.  Will need abx plan, ID follow up, and IR drain checks weekly before discharge." 
    • Set the tone for the team.  Demonstrate how you think interactions should go with patients, consultants, nurses, PCAs, environmental staff, BAs.
    • Take care of yourself and look out for each other. This year has its own unique stresses and challenges. If you do not feel well, speak up. If somebody else seems to be struggling, reach out gently and directly. "Seems like things are rough for you right now. I'd like to hear about it. Do you want to get coffee?"
  • Ethan Bernstein: I always try to give my PGY1s the opportunity to devote as much of their day as possible to direct patient care.  This is not just time spent at the bedside, but also, clinical decision making.  It is so easy to just put in orders or tell your intern which orders to put in.  "What are your thoughts on diuresis for Mr. Smith today?" empowers your intern to make an independent decision, directly contribute to patient care, and learn from this simple task.  "Put in 40 mg IV Lasix for Mr. Smith," reduces your intern to the role of a scribe.  
  • Lindsay Vendetta: It’s okay to be unsure - there’s always a friend around to listen to your ideas. Remember humor is a mature coping mechanism and can make long days seem much brighter. Always listen to nurses, respiratory therapists, PCAs, and sitters - they spend a lot of time with your patients. And when you need a little extra assistance, just change your MHB unit to “NROC” and you have swat nurse contact information at your fingertips!
  • Steffne Kunnirickal: This is really the time when you are going to grow as a clinician. You will be challenged with diagnostic dilemmas and tough management decisions. The key is to ALWAYS ASK FOR HELP. Just like when you were interns and ran even a potassium repletion by your resident, feel free to run management decisions by a PGY-3 (esp in the first few months). Nobody is going to judge your fund of knowledge or think any less of you for asking questions. Always remember that your primary duty is to do what is best for your patient. Try to listen in and learn about patients on your sister side as well. You will be cross covering them. In addition, the more exposure you get, the better it is. It is also another chance to learn the thought process of your co-resident. You will learn from each other. Remain humble. Remain curious. There is always something more you can learn. Also remember that as a PGY-2, you will be spending more hours in the hospital. Use that time wisely. And always watch out for burnout. 
  • Vivian Ortiz:
    • Don't forget where you came from. Remember that you once were slow, did not make sense in your assessment sometimes, had post-call delirium during your 28-hr calls, and simply, just didn't know it all sometimes. Be patient with your interns. You were there once.
    • You set the tone of the team. Your interns will be nervous if they sense you stressed, they will be unhappy if you're unhappy, they will find joy if you show excitement... Try to relax, even if you are insecure inside, as this will help your interns build confidence in you.
    • You have the choice of being a team-player and make your interns shine or be the opposite. I hope you choose to support your interns and stand with them even through mistakes. Remember that you are a team, in good and in bad times.
    • You don't have to stop playing doctor when becoming a second year. Take the time to also examine patients and talk to them so you know your patients just as well. Your responsibilities shift and grow, but you are always a physician.
    • Rely on your sister team and work with them. They are your biggest help. 
    • If you don’t know, seek help. It's okay. 
    • Check in on your interns about their overall well-being periodically, and always be mindful of their body language. It will help you identify times of stress or trouble. Do this especially after codes as everyone processes these situations differently.
    • Take the time to get to know your interns during the first few days. It will help you figure out how to accommodate to them, the tone in which you interact with them/teach them/give them feedback, etc.
  • Phil Nickerson: The first few weeks of PGY2 are a big change - all of the sudden there is no resident to run things by; the intern is asking questions and you have to come up with answers.  One of the things I learned throughout the year is how often there isn't a single right answer, which is one of the things that makes medicine fun.  As the year went on I found I enjoyed acknowledging uncertainty about certain issues (should we give this patient fluids? what anticoagulation agent should we use? what do we do when the patient's goals and preferences differ from the "optimal" treatment regimen? etc) and having a conversation with the intern about what reasonable choices might be, what pros and cons were, and then seeing what the intern thought and what they preferred to do.  Second year is exciting because you begin to learn what kind of doctor you are - are you more aggressive with treatment?  are you more conservative and tend to prefer a "watch and wait" approach?  The thing that makes being a doctor fun is understanding these grey areas and figuring out how you like to approach them.  At second year I vacillated between periods of feeling more confident that I actually knew what I was doing and feeling hopelessly inadequate.  But, the one thing I can say is by the end of the year I had learned so much and felt a lot better about knowing how to manage certain things and also knowing when I needed help.  Everyone I worked with last year was a great intern and I know you will all be great residents.  And remember the PGY3s are always to here to help in any way we can. 
  • Leila Haghighat:
    • Remember there is a reason for teams being made up of both interns and residents. Especially in the beginning of PGY-2 year, I came in early to do my own pre-rounding because it was habit, and it felt almost irresponsible not to. But often, my work was redundant. Skimming through charts before rounds is appropriate, but the energy expended in replicating an intern’s work can better serve the team by being directed elsewhere. For example, instead of pre-rounding in the traditional way, a resident could spend the first part of the day communicating with care coordinators to ensure a pre-11 am discharge, checking in with an intern to review any major clinical changes they may want to implement before rounds, managing critical situations so interns don’t feel stressed about having to still pre-round on their other patients, preparing a fully charged WOW…
    • It’s still ok to ask anyone for help, from co-residents to chiefs, fellows, and attendings. 
  • Eric Jordan: One of my worries at the beginning of second year was that I would be expected to know everything, especially on sub-specialty rotations I had never done before. Please understand that you're not expected to know everything already, and that you probably know a lot more than you give yourselves credit for. The fellows and attendings will quite often handle certain specifics (like what chemotherapy to use on the Duffy service) and you will be able to deal with the more common medical problems. Remember that there are so many layers of support in the hospital (including your friendly PGY3's!) and that knowing when you need to ask for help is a sign of strength. 
  • Jason Bonomo
    • You’ve got this. I know this because I've worked with many of you, and have heard how strong all of you were as interns from the other now-PGY3s.
    • Autonomy/Supervision: One of the areas I struggled with as a second year was balancing autonomy with appropriate supervision. What have I found that helps? First, always talk with your interns about expectations. Try to get this done on the first day, and don't keep pushing it back (even if it can seem a little awkward at first). Talk about how you expect the interns to pre-round, write notes, put in labs, work on signout, and update family/consultants as needed (if these are indeed your expectations). Run the list after rounds, and offer to pick up tasks (especially if it's a busy service). Early on in the year, you might want to check in more often (maybe every hour) to see how your intern is doing, and also to see how you can help them out. Generally, after doing this for a couple of days, you can get a good sense of where the intern is at and check in less frequently. Let them present their plans on rounds, and then talk about them as a team (and always feel free to help them out so they look like superstars). You'll have interns that may need a little extra help early on, and if it's 5pm and they're still struggling with notes, talk to them to see what's been the biggest challenge. Little things like offering to hold the pager if it's busy can really make a difference. 
    • Rounds: On rounds, you're the team leader. Little things like having a patient list for the attending ready, knowing where to start rounds, and proactively getting nursing staff involved will make everything run more smoothly. Try to give your interns and med students anticipatory guidance on how long their presentations should be. The more teaching done on rounds, the slower the rounds will go. Sometimes it's really great to aim for one teaching point per patient, and if there's a particularly interesting topic, revisit it later on in the day to keep things running efficiently. You can also think about when you want to finish rounds by so that you can make it to morning report. I've had some attendings use timers set at 8minutes to keep us on time. Particularly difficult patient? See them last. Is the intern finished with their work at 3pm -- and you've already got some teaching in? Send them home so they don't break duty hours!
    • Calling Back-Up: Rarely, you'll be in a situation where you seem stuck or overwhelmed by patient care responsibilities (tends to happen at the VA). I think it's better to touch base with your attending and/or the chiefs earlier on in the shift to discuss concerns. If it's 8pm and you've already had 10 admissions at the VA, it would be totally reasonable to call the chiefs and talk about backup. 
  • Mark Connor:
    • Ask the third years for help. Most of the frustrations with becoming a resident have little to do with medical knowledge. Rather, the frustrations stem from various hospital policies, workflows, and EMRs. For example, converting someone from OBS to Inpatient at the VA is not self-explanatory and can take a while to work through. Don't waste your time, just send a message to a PGY3.  
    • Discharge summaries do not need to be a day by day summary of the hospital course. The discharge summary is for the outpatient providers and they don't have time to read through a daily account of the hospitalization - include pertinent information, summarize when appropriate, and be clear with follow-up and outpatient management. 
    • Sometimes you will have to be a mediator between a miscommunication or poor communication between your team and the nurses. If a nurse or charge nurse asks to speak with you, remember that we are all on the same team and our collective goal is caring for the patient. Acknowledge the issue/frustration, determine what will be done, and then move on.
    • Feedback sessions on rotations shouldn't be a compliment shower. Although nice to hear, it is the resident's job to keep the intern moving forward and improving their skills as a physician. Own this role and take pride in the progress of your intern. 
  • Mollie Tucker:
    • Give your interns feedback throughout the rotation, not just at the end. For example, watch them lead a goals of care conversation, you can coach them before and give feedback afterwards.
    • Give your interns space to grow:
      • Work in another room for some time during the day - they know how to reach you –
      • Manage quietly - know everything that is going on with your patients and what needs to happen, but give your interns time to figure things out especially for non-urgent issues
      • Let your intern talk first when you are running the list
    • General advice: You have more responsibility and autonomy this year, but there is always someone around you can ask for help - to start, your co-residents are an amazing resource of medical knowledge and systems knowledge.

So much wisdom, and so much more out there for the asking!

PGY2 year was the best year of my residency.  It is a time for personal and professional growth, a chance to test yourself, to try doing things your own way, and to master new challenges and responsibilities.  It’s exhilarating.

And so, a final word to our PGY2s: You will come into your own this year.  You will gain wisdom and maturity.  You will make key decisions.  You will teach and you will lead.  You’ve worked hard and you are ready.  You will have a phenomenal year.  And don’t forget, your PGY3s, Chiefs, and faculty are right there with you.

Mark  

PS Enjoy this glorious summer day.  I’m going out for a bike ride, then for French Toast at Fig, and then back to finish off 33 (yes 33!) letters of recommendation for fellowship.

M

Submitted by Mark David Siegel on July 08, 2018