1. How to be a good intern AKA: AKA: PGY-1 PGY-1 R-1 R-1 Wedge Wedge

2. Why be a doctor? An opportunity to participate in the center of the human drama: Life and death, not life on the periphery

3. Growing up medically:

4. Internship is the seminal year of your career You will work harder (I hope) You will work harder (I hope) You will learn more You will learn more You will acquire more responsibility You will acquire more responsibility You will form work habits for a lifetime- good or bad You will form work habits for a lifetime- good or bad

5. Mandated intern hours: “The lines Mundy previously mistook for life experience are the lines of an overindulged child who has never been beaten up by anybody’s police or crossed bad borders, or been locked away in the White Hotel or hog-tied and chained to the floor of a helicopter. In this respect he embodies what Mundy considers the least attractive characteristic of both our Western leaders and their spokesmen: a levitational self-belief that nimbly transcends the realities of human suffering.” John Le Carre: ABSOLUTE FRIENDS “The lines Mundy previously mistook for life experience are the lines of an overindulged child who has never been beaten up by anybody’s police or crossed bad borders, or been locked away in the White Hotel or hog-tied and chained to the floor of a helicopter. In this respect he embodies what Mundy considers the least attractive characteristic of both our Western leaders and their spokesmen: a levitational self-belief that nimbly transcends the realities of human suffering.” John Le Carre: ABSOLUTE FRIENDS The rule makers may not always get the picture. The rule makers may not always get the picture.

6. Mandated intern hours: However misguided we may find these rules, they are the rules and must be followed. However misguided we may find these rules, they are the rules and must be followed. “I’m not going to be one of those people who gets old and says ‘I wish I had done this. I wish I had done that.’ Every once in a while, you’ve got to do something hard, do something you’re not comfortable with. A person needs a gut check.” U.S.Marine, Fallujah, DMN 11/21/04 “I’m not going to be one of those people who gets old and says ‘I wish I had done this. I wish I had done that.’ Every once in a while, you’ve got to do something hard, do something you’re not comfortable with. A person needs a gut check.” U.S.Marine, Fallujah, DMN 11/21/04 Regardless of the rules, this is your year to do something hard. Regardless of the rules, this is your year to do something hard.

7. Internship: 1967 Every other night on call. Every other night on call. ½ dozen antibiotics ½ dozen antibiotics ½ dozen cardiac drugs ½ dozen cardiac drugs Very limited radiology Very limited radiology Interns do much lab work, draw blood, start iv’s, pass NG tubes, foleys, etc. Interns do much lab work, draw blood, start iv’s, pass NG tubes, foleys, etc. Wages $5100 Wages $5100 Interns bitch a lot Interns bitch a lot

8. Internship: 2 2005 Every 4 th night, off at 1330, limited hours. Every 4 th night, off at 1330, limited hours. Dozens of antibiotics. Dozens of antibiotics. Dozens of cardiac drugs. Dozens of cardiac drugs. Numerous, complex imaging techniques. Numerous, complex imaging techniques. Interns write lots of orders. Interns write lots of orders. Interns uncertain as to location of veins. Interns uncertain as to location of veins. Interns uncertain as to location of lab. Interns uncertain as to location of lab. Invasive radiologists do lots of procedures. Invasive radiologists do lots of procedures. Wages $35,000+. Wages $35,000+. Interns bitch a lot. Interns bitch a lot.

9. The difference: 1967: Learning by passive absorption 1967: Learning by passive absorption 2004: Learning by active transport. 2004: Learning by active transport. You will have (relatively) a great deal of free time; how you use it will have a major impact on your skills as a physician. You will have (relatively) a great deal of free time; how you use it will have a major impact on your skills as a physician.

10. Learning: Look things up: Look things up: 1967: The Index Medicus (tedious) 1967: The Index Medicus (tedious) 2004: Pubmed, Uptodate, etc., etc. (easy) 2004: Pubmed, Uptodate, etc., etc. (easy) Look things up: Look things up: 1967: Later 1967: Later 2004: Real time (like now) 2004: Real time (like now) A compassionate physician who is inept is still inept. A compassionate physician who is inept is still inept. Don’t operate on hearsay. You have to read. Don’t operate on hearsay. You have to read.

11. “You frag ‘em, we bag ‘em.” Motto on a mortuary truck, Vietnam. “The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering.” U.S. Institute of Medicine Report “The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering.” U.S. Institute of Medicine Report Try really hard not to add to the burden of iatrogenesis. Try really hard not to add to the burden of iatrogenesis.

12. “In 1952, penicillin was fully effective against all strains of staphylococcus bacteria, to such an extent that by the early 1960s the U.S. surgeon general, William Stewart, felt confident enough to declare: ‘The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.’” Bill Bryson: A Short History of Nearly Everything. “In 1952, penicillin was fully effective against all strains of staphylococcus bacteria, to such an extent that by the early 1960s the U.S. surgeon general, William Stewart, felt confident enough to declare: ‘The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.’” Bill Bryson: A Short History of Nearly Everything. Beware of medical hubris. Beware of medical hubris.

13. Work habits:

14. Do it right: admitting patients. Proper H&P- all the stuff they told you in medical school. Proper H&P- all the stuff they told you in medical school. Yes, you need a ROS. Yes, you need a ROS. Illegible notes don’t help a whole lot. You can actually use more than one page. Illegible notes don’t help a whole lot. You can actually use more than one page. You can’t hear through clothing. You can’t hear through clothing. Rectal and pelvic and eye ground exams. Rectal and pelvic and eye ground exams. Problem oriented notes. No loose ends. Revisit and revise your list daily. Problem oriented notes. No loose ends. Revisit and revise your list daily. Get the old records on admission. And read them. Get the old records on admission. And read them.

15. Do it right: Discharging patients. Discharge summaries are important- do it now. Concise, to the point, with meds. Discharge summaries are important- do it now. Concise, to the point, with meds. Fill out the summary (patient instruction) sheets. Fill out the summary (patient instruction) sheets. Patient instructions: the most important: Patient instructions: the most important: Nature of illness and diagnosis Nature of illness and diagnosis What was done What was done Medications: what they are for, how long to take them, refills? Can the patient afford them? Can she read your list? Medications: what they are for, how long to take them, refills? Can the patient afford them? Can she read your list? Followup: when, where, with whom, and what to watch out for. Followup: when, where, with whom, and what to watch out for.

16. Getting along with people:

17. “It is for you to give the Orders & if they are bungled – except for the King, the Archbishop of Canterbury & the Speaker you can sack anyone & everyone – Therefore with this terrific power you must combine urbanity, kindness and if possible Olympic calm....I cannot bear that those who serve the Country & yourself should not love you as well as admire and respect you – Besides you won’t get the best result by irascibility and rudeness. They will breed either dislike or a slave mentality....” Clementine Churchill to Winston Churchill, 1940 (Jenkins, R.: CHURCHILL)

18. Don’t be arrogant: There are no ancillary personnel There are no ancillary personnel There is no excuse for discourtesy There is no excuse for discourtesy Don’t yell (even quiet sarcasm has its limits) Don’t yell (even quiet sarcasm has its limits) Dress to make your mother proud Dress to make your mother proud Remember, you know a lot, but you really don’t know much (and you’ll never know enough) Remember, you know a lot, but you really don’t know much (and you’ll never know enough) There are some really smart RN’s, therapists, etc. around here- consider their suggestions seriously. There are some really smart RN’s, therapists, etc. around here- consider their suggestions seriously.

19. Yeah, we know it’s hard: However: However:

20. “80% of life is showing up [on time]” -Woody Allen Be where you’re supposed to be when you’re supposed to be there. Be where you’re supposed to be when you’re supposed to be there. Doctors have no more excuse for tardiness than anyone else. Doctors have no more excuse for tardiness than anyone else. See “don’t be arrogant.” See “don’t be arrogant.” Conferences, meetings, rounds start on time. Be there. Conferences, meetings, rounds start on time. Be there. Learn to organize your time - now. Learn to organize your time - now.

21. You only get a maximum of 5 admissions. You only get a maximum of 5 admissions. Don’t complain too much. Don’t complain too much. Excessive bitching leads to tedious, repetitive, lengthy anecdotes (war stories) from aging attending physicians. Excessive bitching leads to tedious, repetitive, lengthy anecdotes (war stories) from aging attending physicians. Avoid these at all costs. Avoid these at all costs.

22. You think you’re having a tough day?

23. Sick People

24. “We must walk this lonesome valley “We must walk this lonesome valley We have to walk it by ourselves O, nobody can walk it for us We have to walk it by ourselves.” African-American Spiritual

25. “Now, wearily, desperately, the old enfeebled mind was trying to grope with the strange and bitter miracle of life, to get some meaning out of that black, senseless fusion of pain and joy and agony, that web that had known all the hope and joy and wonder of a boy, the fury, passion, drunkenness, and wild desire of youth, the rich adventure and fulfilment of a man, and that had led him to this fatal and abominable end.” Thomas Wolfe: OF TIME AND THE RIVER.

26. Illness is personal tragedy. Illness is personal tragedy. The emotional impact of a life-threatening illness cannot be exaggerated. The emotional impact of a life-threatening illness cannot be exaggerated.

27. Sickness: Inconvenience. Inconvenience. Interference with recreation. Interference with recreation. Loss of control. Loss of control. Loss of livelihood. Loss of livelihood. Embarrassment. Embarrassment. Pain. Pain. Fear. Fear.

28. Discuss emotional issues openly with patients. Discuss emotional issues openly with patients. Talk to families. Talk to families. Don’t avoid the dying patient or talking about death. Don’t avoid the dying patient or talking about death. Take advice from the nurses; they’re around the patient much more than you. Take advice from the nurses; they’re around the patient much more than you. The most skilled physician who lacks compassion isn’t worth much. The most skilled physician who lacks compassion isn’t worth much.

29. Learning from your patients:

30. “I am in awe of them, and I feel privileged to have been a witness to their lives and their sacrifices….As I came to know many of them and their stories, I became more convinced of my judgement on that day marking the fiftieth anniversary of D-Day. This is the greatest generation any society has produced.” Tom Brokaw. The Greatest Generation. “I am in awe of them, and I feel privileged to have been a witness to their lives and their sacrifices….As I came to know many of them and their stories, I became more convinced of my judgement on that day marking the fiftieth anniversary of D-Day. This is the greatest generation any society has produced.” Tom Brokaw. The Greatest Generation. Get to know your patients. Look at the pictures on the nightstand. Everyone has a story. You will be richer for hearing it. Get to know your patients. Look at the pictures on the nightstand. Everyone has a story. You will be richer for hearing it.

31. Propriety:

32. Patient privacy: Don’t gossip: this includes your spouse, significant other, friends, colleagues. Don’t gossip: this includes your spouse, significant other, friends, colleagues. Knock; close the door, pull the curtain. Knock; close the door, pull the curtain. Talk about sports in the elevators. Talk about sports in the elevators. Spare patients embarrassment whenever possible. Spare patients embarrassment whenever possible. It embarrasses me that someone thought we needed HIPPA. It embarrasses me that someone thought we needed HIPPA.

33. Frustration

34. Frustration: “Life is not fair.” Your mother “Life is not fair.” Your mother “Life is hard, then you die.” Gabriel Shapiro, oncologist “Life is hard, then you die.” Gabriel Shapiro, oncologist “If you want justice, go to divinity school.” Bruce Johnston, Seattle attorney. “If you want justice, go to divinity school.” Bruce Johnston, Seattle attorney. Illness is terribly unfair- at times overwhelmingly so. Illness is terribly unfair- at times overwhelmingly so.

35. Frustration: “A passive airbag is clearly a supplemental safety device; it’s reasonably effective, though- like the rest of life itself- not without tradeoffs. If you do choose to ignore the seatbelt, the rest of us shouldn’t honestly care what the airbag does to you.” Dennis Simanaitis, Road & Track, June 1997. “A passive airbag is clearly a supplemental safety device; it’s reasonably effective, though- like the rest of life itself- not without tradeoffs. If you do choose to ignore the seatbelt, the rest of us shouldn’t honestly care what the airbag does to you.” Dennis Simanaitis, Road & Track, June 1997.

36. Frustration: “Why should I be out here risking my life when people are doing this shit?” U.S. Marine infantryman, commenting on a drive-by shooting. “Why should I be out here risking my life when people are doing this shit?” U.S. Marine infantryman, commenting on a drive-by shooting.

37. Frustration: Non-compliance is a fact of life. Non-compliance is a fact of life. People do stupid, dangerous, repulsive, reprehensible things. People do stupid, dangerous, repulsive, reprehensible things. We have to treat them anyway. We have to treat them anyway.

38. “Who is John Galt?” Ayn Rand: ATLAS SHRUGGED. Learn to deal with the bureaucracy. Learn to deal with the bureaucracy. Pick the mountains you want to die on (Bruce Wall.) Pick the mountains you want to die on (Bruce Wall.) Don’t “go along to get along.” Don’t “go along to get along.” Occasional hell-raising ain’t so bad. Occasional hell-raising ain’t so bad.

39. Integrity: “The acceptance of individual gifts, hospitality, trips, and subsidies of all types from the health care industry by an individual physician is strongly discouraged. The acceptance of even small gifts has been documented to affect clinical judgment and heightens the perception (as well as the reality) of a conflict of interest.” “The acceptance of individual gifts, hospitality, trips, and subsidies of all types from the health care industry by an individual physician is strongly discouraged. The acceptance of even small gifts has been documented to affect clinical judgment and heightens the perception (as well as the reality) of a conflict of interest.” Ethics Manual, ACP, Ann.Int.Med 142:572

40. Integrity: The lure of money: Buick vs. BMW. The lure of money: Buick vs. BMW. Medical fads- cashing in. Botox anyone? Viagra? Medical fads- cashing in. Botox anyone? Viagra? Professional witnesses. Professional witnesses. The drug companies. Are you for sale? What are you doing for dinner? The drug companies. Are you for sale? What are you doing for dinner?

41. Citizenship and Social Responsibility Stepping outside the medical box. Stepping outside the medical box.

42. Be a citizen: Participate in the community. Participate in the community. Many of the health issues of this era must be solved at the community rather than the individual level. Many of the health issues of this era must be solved at the community rather than the individual level.

43. “The things that will destroy America are prosperity at any price, peace at any price, safety first instead of duty first, the love of soft living and the get-rich-quick theory of life.” “The things that will destroy America are prosperity at any price, peace at any price, safety first instead of duty first, the love of soft living and the get-rich-quick theory of life.” Theodore Roosevelt

44. Being a physician does not absolve you of other social responsibilities. “Underlying such privatization is a misguided belief that the elite can remain unaffected by the problems of society around them: the attitude of those Greenland Norse chiefs who found that they had merely bought themselves the privilege of being the last to starve.” “Underlying such privatization is a misguided belief that the elite can remain unaffected by the problems of society around them: the attitude of those Greenland Norse chiefs who found that they had merely bought themselves the privilege of being the last to starve.” Jared Diamond: COLLAPSE

45. Scared yet?

46. Medicine: An endurance sport? An endurance sport? A religious calling? A religious calling?

47. Balancing detachment and compassion. “We were eating supper and they brought in one of the locals who had been shot in the head. There was nothing we could do for him, so we dragged his stretcher out into the field, and went back to finish supper.” U.S.Army major, Nicaragua, 1972. “We were eating supper and they brought in one of the locals who had been shot in the head. There was nothing we could do for him, so we dragged his stretcher out into the field, and went back to finish supper.” U.S.Army major, Nicaragua, 1972. Learn to leave it at work. Learn to leave it at work.

48. Personal Keep you profession and your family central in your life; you won’t have time for much else. Keep you profession and your family central in your life; you won’t have time for much else. Don’t overspend or become obsessed with money. Don’t overspend or become obsessed with money. Alcohol and drugs are real hazards. Alcohol and drugs are real hazards. Go to the gym. Go to the gym. Read a non-medical book. Read a non-medical book. If you feel depressed, talk to one of us- don’t wait for a crisis. If you feel depressed, talk to one of us- don’t wait for a crisis.

49. “The loneliness of the long distance runner.” 1962 film. You’re better, and tougher, than you think you are. You’re better, and tougher, than you think you are. Things nearly always work out. Things nearly always work out. This day, too, will pass. This day, too, will pass. Enjoy the next forty years. Enjoy the next forty years. Most of you will. Most of you will.