Becoming a PGY2

Hi everyone,

We’re halfway through the academic year, and, in just six months, 46 of you will become PGY2s, leading teams, running codes, and doing the “senior” thing. You’re all on track, but some (all) of you undoubtedly wonder if you’ll be ready.

It’s less nerve-racking to become an intern than a PGY2. Interns need to show up and work hard, but there’s always a senior watching over you. But when you become a PGY2, the interns will turn to you. Nurses will ask you to make decisions, sometimes fast. And attendings will leave you in charge, murmuring something about “calling anytime."

We’ll do our best to reduce your stress. At the JAR Retreat in May, we’ll share tips and tricks. The attached Intern Milestone grid—developed by our residents—will help you track your readiness. You can treat the next six months as a dress rehearsal to prepare for the show. You should master paracenteses, ABGs, and ultrasound-guided IVs; write discharge summaries; join care coordination rounds; lead RRTs and codes; teach medical students; and run rounds. You can trade places with your senior and let them be your “intern” for a day or two. When you’re up for it, you can ask your senior to leave the floor so you can practice “resinterning,” to show you’re ready to go solo when your intern has the day off.

All 91 of our seniors sailed through the transition to PGY2. This morning they’ve shared a gold mine of pro-tips. Read away!

Enjoy your Sunday, everyone. I’m heading out to East Rock for a hike,

Mark

P.S. What I’m reading:

• The Terrifying Realization That an Unresponsive Patient Is ‘Still in There’ By Daniela Lamas
• You Don’t Get Disasters Like the Palisades Fire Without Human Failure By David Wallace-Wells
• A Big Idea to Solve America’s Immigration Mess
• ‘Now Is the Time of Monsters’ By Ezra Klein
• All The King’s Men by Robert Penn Warren
• Timeless Advice on Mental Health, Trauma, and PTSD for those devastated by the fires (A Facebook post by our own Dr. Juliette Spelman)

P.P. S. Advice for rising PGY2s from seniors, Chiefs, and an APD:

• Abdel Abushouk, PGY2: In my experience, being a senior is all about 2 key qualities:
  • Seeing the bigger picture: What is the primary pathology in this patient? Can I fix everything? Should I try and fix everything? Does this patient with limited life expectancy really need to be on a statin? Well, how limited? What does the patient think? What are their goals? Another example: On the wards or in the ICU, hundreds of clinical data points will be thrown at you every day, many of them abnormal. It is always important to take a step back and think whether these abnormalities are the primary drivers of the patient's illness or just secondary manifestations of the underlying disease process.
  • Be the senior you wish you had as an intern: Think of something your senior did that you appreciated and promise to do it for your interns; Or something your senior did and you wished they did differently, and try to avoid it. Right now, you have the opportunity to shape what kind of senior you are going to be in 6 months.
• Dorian Kaminski, PGY2: I think I have a few tips that seemed to have serve me well:
  
  • First, walk around the unit and just chat with the nurses taking care of your patients, especially at night. I’ve received really heartwarming feedback from the nurses that the presence of a physician who is interested in their concerns, as well as just interested in them as people, is so helpful to them and makes them feel supported. Some of my best friends both at and outside of work are nurses and getting to know them is indispensable for my own wellbeing and the wellbeing of the patients. This also gives the intern an opportunity to think and work alone and cultivate their independence.
  • On a related note, taking the concerns of nurses seriously and cultivating a shared mental model can only benefit patients. I’ve seen people scoff at nursing concerns but I’ve found that simply explaining your rationale for a particular decision early in a rotation gives them confidence in you as a leader and improves buy-in on the backend.
  • Third, take patient vital sign changes seriously. This doesn’t mean freak out/lose your composure at one single data point, but don’t be lulled into a false sense of security because a patient “has done this before” or looks well with very abnormal vital signs. Consider the trajectory over the next few hours and anticipate pitfalls and plan for all possible outcomes. Often abnormal vitals precede obvious outward signs of decompensation (e.g. mental status changes, worsening blood gasses, etc.). I’m usually not surprised by patient deterioration nowadays because I keep close tabs on their vital signs (I like the vitals and glucose icon on my EPIC list which turns red based if they fall outside parameters I set). Often we can prevent escalation by considering patient physiology and being proactive! This doesn’t mean reflexively bolus every hypotensive patient (god forbid) but it does mean thinking about why the patient is hypotensive and discussing contingencies with the nurses.
  • A corollary is to look at the respiratory rate yourself and assess work of breathing when you’re worried about someone. It can be difficult to predict who will decompensate; some folks look awful and keep chugging along, some crash very quickly without looking too bad. If you’ve seen the patient, you’ll have a framework in your head for management if something bad does befall them.
  • Go to codes, rapids, etc. and participate if you know what to do or watch how others operate if your presence isn’t intrusive/there aren’t too many people. You quickly pick up the instinct to double check that things are actually being done, that meds are on the way, that anesthesia is actually coming down the hall, etc. Practice bag valve mask ventilation if you come across a mannequin in the hall and you’re allowed to use it (this seems to be popular at the VA).
  • Praise your team often. Go out if your way to do things for them. Empower them to make their own decisions. Correct gently if their decision making is suboptimal (this is rare in my experience). Get excited about medicine and express that excitement.
  • Finally, if you are able try to kneel down to the eye level of a patient. As a senior your contact with patients is more limited and you need to build trust early with less time at the bedside. This is a quick tool to make people feel like you’re listening to them. If you have bad knees or other reasons why you cannot kneel, try to find a chair.
• Cristian Pena, PGY2: Here are more than a few pointers I think the transitioning interns can benefit from:
  • Creating good habits, your intern is watching you: The nurse who texts about a prn Ativan for an agitated patient, certainly easier to just place the order and call it a day, which I have seen done. However, there is value in going to the bedside with your intern, and having a conversation about whether this patient is directable, whether we can manage verbally or with something more benign i.e., trazadone. Is our patient agitated because they are in pain, delirious, or because there is a clinical change in their condition, is something brewing? Take 5 minutes to see the patient together, and refrain from dishing out PRNs without first evaluating the patient. Think critically about length of time you want a prn active.
  • Know your environment, know your resources, reinforce these to your intern: Unclear about dosing for lidocaine in the CCU, ask your pharmacist. Need help converting an insulin drip in post DKA protocol to scheduled insulin? Ask your pharmacist. Don't understand the ventilator wave forms, or modes, or is the ventilator making weird alarms, ask your respiratory therapist. You’re new to a service and check on your patient in the morning and something doesn't seem right, ask your nurse about their impression, have they covered this patient before? Any changes from their end? Anything notable in their report from overnight?
  • Encourage your intern to take charge in acute situations, when ready, talk about this at the start of the rotation: In the heat of a rapid, code, or if someone is teetering, it's difficult to take the time to slow down and think about your interns learning (at least at my stage). Talk to your intern at the start of the rotation. If there is a code, do they want to run it? Or do they want to observe/time, proceed to reviewing ACLS hypotheticals together. If there is a rapid, do they want to run it? If yes, tell them to take charge as soon as we go into the room, stand at the foot of the bed, reassure you will be there for back up and guidance. Have this conversation early, set the expectation.
  • Debrief every and all acute situation together, ideally with the attending involved. Why did this patient deteriorate? Could we have caught this earlier? Did we communicate appropriately? Were we thorough? Anything we could have missed now that the patient is stable? What could we do better next time? Always notify your attending if you are worried about someone deteriorating, considering escalation, or if you feel out of your depth.
  • If your intern comes to you with a problem or clinical question, encourage them to also come to you with a solution instead of just handling it or telling them what to do. I.e., The patient is in persistent RVR despite escalating doses of metop? What other nodal blockers can we use? Is it safe? What's their EF? Why are they in a fib? Can we chemically cardiovert? Do we start amio/dig/do we call cardiology? When should we call cardiology? Encourage your intern to come up with a plan (if appropriate based on acuity of situation) talk about it together. Each problem has countless learning points. Patient desatted? BP dropped? Have your intern walk you through a differential as you're on your way to the room to see the patient.
  • For nights: add E cart scores to your list on Epic, see all the patient together who are in the red for a baseline in the event of decompensation, look through their orders, their labs, their recent imaging. Even if not a watcher at sign out, you should consider these patient's watchers.
  • Be kind and be patient with your intern and with yourself, and all those you work with. We are part of the culture of medicine, grow together, look out for one another, and put good energy out there on the wards and in the unit. We are imperfect people practicing an imperfect science.
• Kanika Sehgal, PGY3: As a January intern, I wish I knew that it is okay to not know everything. The goal of residency (and training beyond) is to foster a "growth" mindset and not a "know it all" mindset. The learning curve is arguably even steeper in the beginning of 2nd year, and the learning truly never stops as we progress through training. But if we absorb a little more every day and continue to keep an open mind, all can be conquered. (Also highly recommend the book Mindset by Carol Dweck for anyone interested - I read this around winter of intern year, and it really helped shift my perspective).
• Emily-Rose Zhou, PGY2: Here’s my advice!
  • Congrats! You are halfway done with what I believe to be the hardest year so far of medical training/school. In my opinion, PGY-2 year is so much more fun though it can be a scary jump in new responsibility.
  • To prepare for some of these new responsibilities, this point in intern year, try to ask your senior to teach you how to do discharge tasks—especially at the VA—since that is one of the major learning curves for new seniors. Simple things like knowing how to do a W10, ref34, dc instructions, med rec, beneficiary travel, etc. can help make the transition in June smoother! No need to write dc summaries at this point, as you still have progress notes. :)
  • And if there are still admission tasks (like med rec at VA) you need to familiarize yourself with, ask for opportunities to practice those more independently.
  • Continue honing skills of planning for dispo and recognizing sick from not sick/stabilization—the big picture jobs of a senior.
• Isabel Bazan, APD: My thoughts
  • Come up with a system of how you will keep track of patients! As an intern, you are pre-rounding and writing the progress notes, both ways that really solidify the details of patients histories and active issues, but as a senior resident you need to devise and organizational system by which you will keep track of who is who and figure out what details do I need to know or not. Transitioning your view of patients to more forest from the trees is crucial.
  • All interns learn differently. Meet with your interns at the start of each rotation and get a sense of how they learn best, how much support they would like, what kind of learning environment do they thrive in, etc.
• Victor Jimenez, PGY3:
  • PGY2/3 is not PGY1 on steroids. You will be tempted to do tasks for your intern or finish that H&P that is pending (because you know you can get it done in ¼ of the time). Resist the urge; your role has changed. You are the one calling the shots, the one who NEEDS to understand the big (and small) picture, the one expected to know what to do, which requires different skill sets you need to develop. Your PGY1 superskills will come in handy on resinterning days and on the occasional eight admit day in the VA, but for the most, step back and delegate. We grow when we struggle; let your intern struggle a little bit.
  • Read more, not only the MKSAP summary of a topic, but try to dig deeper into how and why's (mechanisms and evidence). While waiting for sign-out, stop typing on that DC summary (it's already long enough that the PCP won't read it ), open up-to-date, and fact-check your consultants, and answer the questions that arose throughout the day. Sign up for the weekly summaries from NEJM, Lancet, JAMA, etc.
  • Listen to podcasts while you commute: My recs—> Core IM (Best IM podcast), PulmPEEPs, Critical Care Time, the Heme Fellow on Call, Cardionerds, Rheumatology for the Royal College, Febrile and the Internet Book of Critical Care. I'm not a fan of the Curbsiders.
  • Lead by Example: you need to do and embody EVERYTHING you expect from the people you work with. Breathe and keep calm during rapids and codes (if you panic, everyone panics). Remember that the first steps of managing a decompensated patient are always an algorithm (keep it on your phone); you will always have help.
  • Be Humble: you are a senior, but you have a LOT to learn (so does your attending and chair of medicine). Listen to your intern, students, nurses, and patients.
  • Talk to your peers to offload the day's events or share your thoughts about a complex case. You work with brilliant and compassionate people and utilize that resource.
  • Stop and Smell the Flowers: stop and enjoy the small victories; I believe a source of burnout is not giving yourself the time to appreciate how valuable you are to the patient finally leaving EP or the one dying in the MICU with her/his family holding their hand, what you do matters. You have the world's most profound, uncorrupted, and rewarding job.
• Justin Dower, PGY3: Here is some advice to pass along:
  • Think about the rotation where you really enjoyed working with your senior and felt proud of your performance - find ways to create that kind of rotation for your interns. It probably was a combination of pleasant workroom environment, sufficient trust with space to learn and grow, and behind-the-scenes support.
  • Practical advice for discharges:
    • Normal: e-prescribe to outside pharmacies and for meds to beds
    • Print: print a paper Rx to give to the patient. Does not go to the pharmacy.
    • No print: to create an official med list for STRs and other facilities. Does not go to the pharmacy.
  • If a patient is going to a facility but needs to take the meds with them: use Normal for those meds (can get things like antiretrovirals for HIV, etc. that are not available at the destination facility via meds to beds).
• Cosmas Sibindi, PGY3: A piece of advice that I know now which I wish I knew in January of PGY-1 is below:
  • While you have been learning a lot from your patients and time in the hospital, you can still feel a lot of pressure to also be deciding on a specialty and starting research. There is still plenty of time to decide on specialty and also find mentors!
  • Additionally, as your mastery of the intern/medical tasks improves, you will find you have more bandwidth to pursues the same as well!
• Kylie Rostad, PGY2:
  • At this time last year, I felt so behind - I had had very few inpatient rotations and did not feel like I had enough experience. I had a back-loaded year so I knew the experience would come, but I compared myself to the interns around me who had more intensive first blocks and it was not helpful. One thing that helped a lot was referencing the milestone guide for interns. I was able to identify where I needed to go next, and it helped structure my goals for each of my remaining rotations to the point where I felt ready at the end of intern year.
  • Also, do not forget that you are a learner too - it's okay to not know everything and to prioritize learning your role as a senior and furthering patient care. Also, take Step 3 if you can - you have less time as a senior!
• Joshua Rusheen, Chief Resident: Here's my response!
  • You may not realize it but you’re more ready than you think to step into the senior role - trust the foundation you’ve built and embrace the opportunity to lead!
  • One of the most important parts of being a senior is supporting your team and growing together, so focus on lifting each other up and you’ll thrive :)
• Mason Montano, PGY3: A bit of advice for upcoming seniors!
  • Ensure to set clear expectations at the start of the rotation with your interns and check in at least every few days how they are feeling both clinically, emotionally, and physically
  • Assess the proficiency in Epic or CPRS. Part of being a good intern or senior resident is optimizing the workflow and pre rounding. Pass on the helpful hints on how to use the summary tool well!
  • Stop and think about why patients are admitted to the hospital. Your focus must change from the granular approach of getting tasks done and rather to the ultimate goal of the hospitalization, how we can prevent readmissions, and mitigating outpatient care barriers
  • It is okay to ask for help. Ask your co residents, senior residents, and attendings. We are all learners and need to have some humility.
  • If you are not signed off on procedures this is critical to get done. Your interns look up to you, so try to set an example of excellence.
  • Regarding discharges ensure your discharge summary is complete, concise, and easy to understand. Many PCPs only have minutes to read what happened in the hospital so make it distillable.
• Avinash Murugan, PGY3: Here’s a small note from me:
  • Lean on your coresidents when you have questions but also to learn how others approach the same problem.
  • Try to get signed off on key procedures (especially ABGs) soon if possible. Practice thinking about disposition decisions: floor vs escalation, discharge readiness, etc.
  • When in doubt, always go see the patient yourself.
  • Most importantly, have fun - PGY2 is a year full of growth and learning!
• Anthos Christofides, PGY3: I really think that our program does an excellent job of preparing interns for the PGY2 year, and at the beginning of my second year, I never felt unprepared.
  • What helped me most was during my last Yale and VA inpatient blocks, I asked my seniors to let me handle everything myself—including all aspects of the discharges. While every intern by the end of the year knows how to do discharge med recs, there are many small but essential tasks that PGY2s are expected to handle on day one that can sometimes be overlooked. For example:
    • Arranging for home oxygen
    • Ordering DMEs (like walkers or hospital beds)
    • Setting up follow-ups with outpatient providers
    • Ensuring all necessary paperwork is complete for a smooth transition
  • In short, I would recommend that interns take the last few inpatient blocks to do as many discharges as possible, making sure to manage every detail themselves.
• Idil Eroglu, PGY3: What a nice idea!
  • My advice is to keep doing all the same things you are doing as an intern — see the patients, double check the notes, vitals, review results as they come through (use MD notification tab in your list!!), consultant recs, etc. — but in the background.
  • Let your intern do their thing, but always double check in the background and help where you see that your intern may be needing it.
  • Some interns need very little support but some interns may need more, so you can tailor your senioring style depending on their needs.
  • And you still have lots of supervision yourself — attendings (and fellows) are always around for support, so don't feel like you are ever alone!
  • Try to update discharge summaries in your spare time, it makes a huge difference for your cross-covering senior on days off and for the next team.
• Amelia Khoo, PGY2: My advice would be to enjoy the days of being the patient’s “number one!” I didn’t always love being the first one to see a patient in the morning, or the first one that they call upon when they need to speak to one - but now I miss it all the time and recognize it for the privilege it is!
• Christina Cotte, PGY2: I would recommend requesting to be a senior for a day and to ask their senior to go through a discharge checklist for both a VA rotation and a YSC rotation. It helps to be able to ask questions before you are the senior!
• Kaleena Zhang, PGY3: There is always time to pause and think, even when you get that page about an unstable patient. Don't feel pressured to act within seconds - in fact, it's better not to react in haste! Take a breath first, go to the bedside, bring a computer and a colleague or two, know there is always the RRT team if you're stuck.
• Jody Sharninghausen, Chief Resident:
  • I would advise interns to actively observe their senior residents and take note of specific behaviors, attitudes, or skills they plan to emulate. Some examples might include approach to discharge planning (e.g., preparing the med rec with the team on rounds the day before), approach to code status/goals of care discussions, chalk talks/teaching format, checklists or other systems for keeping track of patient lists and tasks, POCUS/procedural skills.
  • Even for those who aren't procedurally inclined, be sure to get signed off on ABGs and be able to do the more challenging ones with POCUS.
• Talal El Zarif, PGY2: This is a cool project. I wish someone walked me through the intern milestones ahead of time so I could start setting more appropriate goals to make sure I'm on track, but things worked out well at the end!