Follow A Day in the Life of an Internal Medicine Resident
Doctor M. is a member of the SketchyMedical editorial board and currently a second year Internal Medicine resident at a Los Angeles hospital. Names have been removed to protect the patients. She has kindly taken the time out of her busy day to share her life as an internal medicine resident for us.
My alarm goes off at 6:30am, a rough start considering I just had two weeks of vacation which meant sleeping in luxuriously. I get ready to go to work, quickly eat some breakfast, and I’m on my way to the hospital. I am currently on a day float rotation in my second year as am internal medicine resident.
Luckily I live about 5 minutes away, so I’m at the hospital and up in the internal medicine workroom by 7:10am. I pull up the list of internal medicine patients I will be covering today, and print out their names, rooms, and the “sign out”. The “sign out” is a document that has the patients key information, including their main medical problems, current condition and assessment, and their current medications. I review each patient and make my own notes on a separate sheet. I do this preliminary review to help me keep up with the day’s rounds and gives me a preview to what we’ll be talking about today. By 7:25am, I am on my way to the post-call room to meet with the team.
The post-call team is made up of the resident (myself), two interns, and a medical student who slaved overnight to admit all the medicine patients. Having been in their shoes before I know how exhausting and overwhelming it can be. These residents likely came in the day before around 6 am, stayed up all night, and maybe got 20–30 minutes of sleep if they weren’t interrupted by pages, and then are expected to present all their patients at 7:30am with the attending. The senior gives a sigh of relief when he tells me they only had five new patients come in overnight. In addition to the 7 “olds”, I’ll be taking care of a total of 12 patients today. I also touch base with the nurses who cared for these patients overnight.
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When the attending arrives (with bagels too!), we are ready to start rounds. I listen along to the familiar pattern of HPI, ED course, PMH, PSH, meds, allergies, family history, social history, vitals, exam, labs, imaging and finally the assessment/plan. While the intern or medical student is talking, I’m in constant motion, pulling up labs and x-rays, reading along with the H&P notes, putting in orders, and occasionally sending pages out to consults.
[Tweet “#residency: pulling up labs and x-rays, reading along with the H&P notes, putting in orders, sending pages out to consults”]
I learn about causes of acute kidney injury and acute interstitial nephritis, and the attending advises us to always think twice about prescribing triple therapy for H. pylori as the medications are not benign. She points out that clarithromycin can affect levels of statins which can result in stain myopathy and precipitate rhabdomyolysis, (which was not the issue in this patient’s case, but was something I told myself I’d keep in my back pocket in case I ever encounter such a case). I hear about a patient with chest pain who turns out to have an NSTEMI, and then two patients with shortness of breath — one with pulmonary hypertension the other with a history of a pneumonectomy. The next patient is the all too common case of urosepsis. At this point it is about 10:00am in the morning. A solid two and a half hours sitting in front of the computer… My FitBit buzzes intermittently begging me to get up and walk around…
We round out our discussion with the patients who had been admitted earlier in the week and were still in the hospital, the “olds.” This involves writing more orders and some discharge orders. Luckily this goes by much quicker and we are able to wrap up in an hour.
I join the attending to see the two neediest patients so I can lay eyes of them before I break off to help the team finish up their work and work through the “to do” list.
I make my way back to the team room and “run the list” with the senior resident on the team. Running the list is a quick review of all of the “to dos” for each of the patients. For example, for the patient who presented with AKI, I quickly rattle off his to dos: “follow-up renal ultrasound, get VBG, give 500 cc over 5 hrs, check urine protein creatinine ratio, place foley”; to which he nods and we move on to the next. In less than 10 minutes I have my finalized to do list, and the overnight team is on their way out. I lucked out with only 11 patients to cover, a rarity for us — most of the time it’s closer to 20 patients. On top of that, another intern joined the team and was following over half the list, so I was able to take more a senior resident role with those patients and allow him to take care of those patients while I provided supervision.
I now prioritize the rest of my day and work on the most important tasks that need to be done first. This involves calling the consults who were not already called so that they can see the patients and round with their Attendings before it gets too late in the day. I put in a few other orders, review a couple labs and notes, and by 12:30pm I am able to get up and grab my lunch.
I pick up my salad and yogurt I packed the night before in anticipation of a busy day at work. I always try to pack a healthy lunch as I never know if I’ll be able to make it to the cafeteria on this rotation as the days can be quite busy — and the cafeteria isn’t exactly known for their healthy options.
There’s something about sitting down and actually eating lunch that, as a resident makes me feel a little guilty. As a resident, there’s almost an unspoken rule that when you can be working you are working, so I sit down in front of the computer and review some of the new results and notes that have popped up and enjoy my lunch at my desk. I know I could take the time to sit outside and eat in the sun, but today the goal is to make sure all the loose ends are tied up and to stay on top of my work.
After my quick lunch, I strike up a conversation with the night float intern. The night float’s job is to cover all the medicine patients overnight. On weekends that means you come in at 12pm and take “sign out” on patients from teams who are finished with their work. By the end of the evening you have 7 team lists to cover which is usually around 80–90 patients, but can go up to as many as 130 patients. Not a simple task.
I explain how a patient of mine needed a peripheral IV placed and the nurses were unsuccessful so they had asked if the doctor could do an ultrasound guided IV. I had only done it once with my attending supervising and was not successful, but it turns out the night float intern had just done a procedure rotation and was familiar with placing them. Since he wasn’t busy (and is extremely kind) he offers to help me with the IV. We gather the supplies and make our way to the patient’s room. Fast forward to an hour later and multiple pokes in the arm, and we leave the room with our heads hung low, unable to get the IV in. Luckily, it was not an emergent necessity and it would be fine to wait another day to get one in, but I felt bad for putting the patient through the attempts.
I start to get nervous around now, as it had been over an hour and a half, with no pages, and no word from the intern who was working with me today; this was very unusual and I was worried something had to be wrong. Turns out it was just my pessimism. I check in with the intern, catch up on more notes and lab results, and make some phone calls.
Somehow its already 4:00pm and the boxes on my sheet have all been checked off. That can only mean one thing to an internal medicine resident: time for sign out.
I print off my list and the intern’s list of patients and the respective “sign out” sheets, and we make our way down to the basement, which are the house staff quarters. These are individual rooms where residents have a bed and a computer, and are usually used by residents who need to stay overnight — although they also come in handy when you really need a nap during the day.
The intern give his sign out first, and I add comments as needed. It is very important to be thorough and do well during “sign out” because when you leave for the day, the night float resident is in charge of your patients (and maybe 80 other ones) and there is no way he/she can possibly know your patients as well as you do. That means you have to explain the most important parts of your patient’s case and anticipate some of the things that might happen overnight. For example, for my elderly patient with dementia and sepsis secondary to pneumonia, I warn the night float about what I would recommend if the patient becomes agitated, or if he/she spikes a fever overnight, if repeat cultures are necessary and should he/she broaden antibiotics. Obviously, it is up to the night float to use his/her clinical judgment, but it comes in handy to have some advice from someone who knows the patient well and has reviewed their history.
By the time we finish sign out its only 4:45pm — a complete miracle. I usually expect to leave around 6 or 7pm on this rotation, but the intern was a great help and we were able to get out earlier than usual.
I make my way home and work out for an hour, cook a healthy dinner, and pack my lunch for tomorrow. Some days I am completely exhausted after a day at the hospital and just want to relax on the couch and order takeout, but I always try to make an effort to exercise and eat healthy. It is really important to me that I take care of my mental and physical well-being so I can be prepared to take care of my patients.
[Tweet “Its important that I take care of my mental and physical well-being so I can best take care of my patients #residency #internalmedicine”]
I then opened up the EMR from home and go over the patients I took care of today, reviewing new notes that were signed after I left and putting in a few orders. Next, I read up on the patients I will see tomorrow.
With an hour to go until bedtime, I close my computer, get ready for bed, and finally relax, letting my mind escape from the busy day I just had and prepare myself for the next day ahead. No day is typical, and so is the life of an internal medicine resident.
As an Internal Medicine resident, every single day is different, depending on the rotations and the patients that come in. This Day in the Life may not be representative of all internal medicine residents, but gives you a glimpse into the diverse career as a doctor.