Why It Took Me 2 Hours To Give My Patient Tylenol
It’s July.
For most people, that’s no big deal. But, if you’re in the hospital, everyone knows that you’re about to be surrounded by new interns. Not only does this mean a bunch of new faces, but everyone will be spending a lot of time helping the newbies out with putting in orders, finding patients’ rooms, and navigating the bureaucracy — not to mention the foundation of medical knowledge they’re still working to build. The halls fill with whispered echoes of comments about “fresh meat” and jokes about trying not to get sick in July, punctuated by elbowing and the occasional snicker when a young doctor overloaded with papers is scrutinizing the directional signage a little too closely (or, if you’re lucky, a genuine offer of “can I help you find something?”)
We were all there at one point. Do you remember what it was like to be that intern?
I do. In fact, I just started my intern year, and I’ve had the privilege of learning firsthand exactly what this feels like. I thought it might be helpful to reflect on it close to the beginning with fresh eyes, as there’s nothing quite like being thrown in the fray for the first time. The experience can be exhilarating, frightening, and a little disorienting. Not only are you suddenly expected to be “The Doctor,” you are also expected to figure out as quickly as possible how everything works in a system with which you may or may not be familiar. This includes such logistical tasks as navigating the hospital halls, learning the electronic medical record system, and figuring out who you should call for a wide variety of things you can’t (and shouldn’t) do by yourself. You’re also a new, key member of a team you may never have met before, and you have to figure out both where you fit and how to make the dynamics work. And, of course, you have to learn how your pager works!
I can’t speak for everyone, but even as excited as I was for the next phase of my training, there was no denying that I was scared going in. As a preliminary intern, I was entering a specialty other than my chosen one, as I must complete a year of internal medicine before continuing on to dermatology. My last clinical experience with internal medicine was in the middle of my third year of medical school, so my learning curve was probably steeper than that of many of my colleagues. Despite the slope of the curve, I was facing the same situation that every intern in my shoes has faced: I would, for the first time, wield the full power and responsibility that comes with caring for another person’s life. In medical school, regardless of our experiences, most of us were aware on some level that we were ultimately not responsible for what happened with our patients — it is impossible not to let that color your perspective, even if subconsciously. But now, that safety net is gone. My name will be on every lab draw and medication order. I will write and sign real notes that tell my colleagues what I think is happening with my patients and what I want to do about it. My word carries (at least a little) weight.
I would be remiss, and my kids would be upset, if I didn’t quote from everyone’s friendly neighborhood web-slinger: with great power comes great responsibility. Interns are right at the tip of that spear. We overthink and obsess, and I like to think that’s a good thing, because we are taking this responsibility seriously. We also have a lot of people watching us closely, so there is a high likelihood that whatever happens to our patients has been thoroughly considered and vetted.
I know all of you have been here, but I also know that it might be hard to remember in the heat of the moment why, for example, it might have taken your intern two hours to get their patient some pain medication. Much of our medical judgment is honed with experience, but it requires a heavy up-front investment of time and effort to get to that point, and as interns, we’re investing heavily.
Let me walk you through an experience I had during my first overnight cross-cover shift that typified this experience for me.
A nurse calls me and tells me their patient would like something for pain. I get more information from the nurse, including a set of vital signs and whether the patient has already taken medicine for pain. I hang up the phone, heading to the computer so that I can look through the chart. Tonight, I’m responsible for somewhere around 60 patients, none of whom I’ve actually seen before. Even though my colleagues have told me about each of them in detail, I’m not going to make any decisions before looking at the chart because there’s no way I can remember everything off the top of my head. I want to make sure I know exactly why this patient is in the hospital, what their medical problems are, what they’ve taken in the past for pain, and whether it makes sense for that patient even to be having pain. I’m new to this electronic medical record, so this search can take some time.
As soon as I’ve had the chart open for two minutes, my pager goes off again. Another patient has vomited blood. I log off and walk briskly (okay, I run) to evaluate that patient, get them treatment, and then do the paperwork and put in orders. When I’m finished, at least 45 minutes have passed. That first patient is still in pain.
I go back to the chart and pick up where I left off. I look through labs to make sure I don’t prescribe any medications that could make any of their existing problems worse. I may have to look up the side effects of some of the medications I’m considering, just to make sure I’m not missing anything. I also want to make sure I don’t give the patient too much of any one kind of medication, so I search through their medication history. While I’m doing this, I answer several more pages, some also asking for pain medication. At least another 45 minutes have passed, and I’m sure that first patient is still in pain.
The last step in this process, once I know what is happening and what medications I could reasonably give, is to examine the patient. I want to lay eyes and hands on them to make sure the pain is not a sign of something more serious. I answer two or three more pages on the way, including one from the first nurse asking about that pain medication. (The nurse has probably at least thought about calling my upper level resident at this point — I’m grateful that she hasn’t.) When I arrive at the patient’s room, they are understandably grumpy because they are in pain and it’s the middle of the night. I ask some questions, do an exam, and then I have to make a final decision about what to give the patient. At this point, I’m confident that the patient’s pain is appropriate and no underlying issues need to be addressed. I’ve thoroughly researched their medical history and lab work, and I think I know what to do.
Then, just for good measure, I call my resident to make sure it’s okay for me to give the patient Tylenol.
The patient is now more cranky. The nurse is exasperated. I can hear my resident rolling his eyes on the phone.
I’m satisfied. I know it may seem excessive to those with more experience, but I still need a safety net for my fledgling judgment. I know how humbling medicine can be, and I refuse to have the hubris to believe that I did not miss a piece of the puzzle at this early stage of the game — particularly because I still don’t even know where to find everything in the EMR.
As this year goes on, I expect to become more confident and efficient as I get a better grasp on the system and as I build even more knowledge. However, I am going to do my best not to forget along the way exactly how much time and energy need to be invested to earn the privilege of being “The Doctor” — to be able to provide medical care to each of my patients — even if it means they have to wait two hours for a Tylenol at night.
Amy Blake is an internal medicine resident and a 2018–2019 Doximity Author. The views expressed herein are solely those of the author and do not necessarily represent the views of any organizations with which she is or has been affiliated.
