“To see the Earth as it truly is, small and blue and beautiful in that eternal silence where it floats, is to see ourselves as riders on the Earth together, brothers on that bright loveliness in the eternal cold – brothers who know now they are truly brothers.”
-Archibald MacLeish, December 1968
On Christmas Eve in 1968, Astronaut Bill Anders captured an indelible image of the Earth rising over the lunar horizon, taken from the capsule of Apollo 8, just before the spacecraft left the moon’s orbit to begin its journey home.
In the picture, the Earth looks lonely and vulnerable, a collage of clouds, oceans, and continents, floating in the darkness, half-hidden and half-illuminated by the sun. From that distance, human troubles are obscured, and it’s tempting to ask how strife could exist on such a beautiful planet.
It’s a wonder that Anders was in a position at all to take this photograph. The Apollo 8 expedition was centuries in the making, born of the dreams and insights of ancient astronomers, made real by the work of modern scientists, and fueled by a president who challenged us to pursue audacious goals:
“We choose to go to the Moon! We choose to go to the Moon in this decade and do the other things, not because they are easy, but because they are hard; because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one we intend to win, and the others, too.”
-President John F. Kennedy, September 1962
As we near the end of 2018, it’s time to set our own audacious goals. Half the academic year is gone now. The interns have mastered note writing, order writing, and multi-tasking. The PGY2s have led their first teams, run their first codes, and made their first crucial decisions. The PGY3s have become leaders and role models, spreading wisdom while beginning to envision lives beyond residency.
So what audacious goals should we set for ourselves as we begin the second half of the academic year?*
For interns, prepare to lead your own teams. Chart your own diagnostic and treatment plans. Take the lead during emergencies. Run rounds. Send your residents for coffee. You’ve got things covered.
For PGY2s, prepare for your capstone year. Step back. Mentor the interns, but give them space to grow. Ask questions, but resist telling them what to do. Teach the students. Consider your own goals because, ready or not, your residency is half way done.
For PGY3s, prepare to be attendings. Lead conferences. Focus on the big picture. Promote patient safety. Continue to mentor your juniors. Set the tone. Leave a legacy.
Let’s all continue to make this the most rewarding year we’ve had. Let’s tackle tough decisions about call and the timing of report. Let’s share our excitement with the applicants. Let’s foster wellness. Let’s nurture joy and meaning in the work we do each day.
In the darkness of early winter, the remaining sunlight seems especially precious, coming to us from the same star that illuminated the Earth fifty years ago, as it posed for that timeless photograph. This morning, let’s pause to appreciate the beauty of our world. Let’s bask in the sun’s remaining glow, and allow its light to shine upon the audacious path we’ve set before us.
Happy everything, everyone,
For further viewing and reading:
*A curated (lightly edited) list of goals for the upcoming year, with special thanks to Solmaz, Harold, Yiduo, Christina, Jakob, Zaniar, Chad, Maggie, Veronica, Hayley, and Eric, and Drs. Dela Cruz and Fogerty:
- Come up with plans for the patient before talking with seniors
- Now that we are more comfortable with epic and note writing we should be able to find more time to search and find the answer to our clinical questions instead of turning to our seniors for guidance
- Take more teaching opportunities in attending rounds and be more responsible for medical student education
- Learn about the logistics of discharging a patient (ex. how to do med-rec for discharge, discharge instructions, follow up visits)
- Learn about discharge summaries (what points will be included, how detailed it should be, when residents start writing it, how often they update it and etc.)
- If we have time we should also attend care coordination rounds
- Try more to present on rounds from memory and give the team the bigger and more important picture
- Try to come up with a list of high yield topics that we should feel comfortable managing them as PGY2s
- I would like to learn more about nutrition and prevention. I feel that we use a lot of generalized terms when recommending lifestyle, diet, and exercise to our patients. Moreover, I would also like to learn more about Enteral / parental feeds, different types of TF’s, and nutritional value/indication.
- I would like to see more Physical Exam clinics/teaching and best practices for descriptions of normal/abnormal exams in documentation.
- I would like to see a basic approach/skills to research methods and reading literature. I would like to learn more techniques to skim a research paper in 3 mins without knowing anything about the topic and assess whether it’s reliable or not. I think journal club is great for topics, but not for mastering this skill.
- Be more confident, be more resourceful, and be ready for what is to come.
- Continue to improve efficiency
- Begin to explore/trial supervising resident role
- Increase teaching on rounds
- Attend care coordination
- Help with discharge summaries when able
- Provide comprehensive but concise notes and presentation; Begin developing impressions and plan for patients before conferring with residents
- Prioritize important tasks (calling consults, placing important orders), complete notes efficiently, sign out with anticipatory guidance to covering team, learn about care coordination
- Practice doing as much of an admission as you can, including putting in important orders and communicating with nurses on the plan once patient gets to floor, all with resident help of course.
- Make notes more concise with only pertinent information. Practice doing this more quickly and efficiently.
- Come up with an efficient way to think about new admissions, especially when there are a few at the same time, and put this into practice as preparation for next year.
- Reading more
- Truly thinking things through
- Staying alert
- To continue thinking in depth about the underlying pathophysiology of a presentation and how it helps form the differential diagnosis
- To continue streamlining my workflow with an emphasis on efficiency as I make my way towards assuming the role of “resident” in a short six months
- To continue incorporating regular reading for learning and for pleasure in my daily activities
- To continue working on having a balance and being able to take care of my own physical, mental, and emotional health, so that I am better able to care for others
- To continue practicing mindfulness and gratitude
- Problem solving
- Medical reasoning
- Perform procedures
- Network with colleagues in the program
- Refine your systems for organization and efficiency. If something about your workflow isn’t serving you, try to recognize it and talk with others who may have a better system.
- Be able to lead the team on rounds
- Inventory your clinical knowledge areas of need, pick one or two, and spend 60 minutes a week reading and learning on those particular areas.
- Explore focused areas for improvement with interns to maximize their growth
- Challenge ourselves to become content experts in topics related to desired field
- Eg – Interested in hematology? Become an “expert” in TLS and be able to teach a high quality mini lecture. Think 3rd year resident peer teaching level.
- Allow PGY1 to be more independent but still provide teaching and support
- Write down less/remember more, assess learners’ needs and adjust teaching style accordingly, teach from primary literature
- Empower interns to take more charge and come up with plans even when it’s uncomfortable, always chiming in at the end and keeping patient safety first.
- Start to think about next steps after residency and prepare for them accordingly.
- Step back and give your interns more autonomy. Try to switch your role to that of teacher and less of “co-intern”
- Move from small picture to big picture with coming up with plans for patients
- Begin your self-development as a leader. There are lots of books about leadership as well as TED talks and documentaries.
- Identify knowledge gaps that can be addressed in their last half year during residency
- Avoid senioritis.
- Envision practicing without anyone looking over your shoulder and implementing high quality and safe patient care.
- Come up with an effective teaching method to try for the second half of the year.
- Increase intern confidence with frequent feedback and passing on pearls that have worked over the past three years.
- Think and act as if you are the attending and there is no one there to check your work or give you the answers. Before you know it, it will be true!
- Be as independent as possible and ready to practice as attendings or fellows
For the residency overall:
- Enjoy the challenges and fun of this life experience.
- Remain a human being. Find something do to outside of work. Anything to find balance in your life.
- Continue to focus on point of care ultrasound
- Increase resident involvement with morning report
- Present patients/clinical background for cases
- Provide quality teaching for content area related to presented case
- Continue to challenge ourselves to provide the best clinical care possible
- Identify future leaders in education, patient care, research, community service and providing these residents resources, teaching, etc to achieve this goal. Develop programs to improve patient experience whenever a house staff is involved in their care.
- Prioritize kindness and respect in all of our interactions at work. In our interactions with nurses, patients, cleaning staff, and everyone else at the hospital, we should be mindful to recognize when we begin to feel negative or defensive because recognizing these feelings is the first step to thinking critically about them and maybe getting rid of them.