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CMR: Chief Middle-management Resident
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Wednesday, November 24th, 2004

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All of the prestige of an intern ... with none of the power

Reflecting on my first call night as an acting intern on medicine, I'm not quite sure when exactly I was the most panicked and unnerved. There were so many opportunities for such feelings to arise ...

Was it when, 15 minutes after the post-call intern signed out to me, a nurse posed a question to me concerning a patient about which I knew next to nothing? Or how about when my H&P on my first admit is interrupted by the arrival of my second admit ... which is quickly followed by the 3rd, filling my quota of three patients, but forcing the third to wait several hours before I could find out her story?

Part of the challenge of the night is the fact that as an acting intern, all of my orders must be co-signed by the senior on call. Who, conveniently, is also the senior for a completely different floor at the same time. So even if I can make a semi-informed decision concerning patient care, I can't immediately authorize the nurse to follow through because I can't write the order.

All of the glory of being an intern (which is practically none), without the ability to make any actions happen on my own.

But I survived the night, mostly unscathed. My other half (two acting interns carry the load of a real intern) was immediately stuck with the task of transferring a patient off of our service because his heart couldn't decide whether it wanted to be in atrial flutter, atrial fibrillation or 3rd-degree block. And, he had no IV access, so we had no labs on him since his arrival from an outside institution the previous morning. Which, because of the quirk of the call schedule meant that neither the intern who admitted him nor the 3rd year medical student who poured over the accompanying fragments of his chart were around to supervise his care in the afternoon. In fact, this patient had been signed out to the two (very-green) acting interns -- only one of whom even had access to the hospital computer system at this point.

My moment in the spotlight came on morning rounds. As we neared the room that housed two of my admits from the night, the chief resident arrived on the floor with a mob of applicants, all nicely dressed in their suits. I stepped aside to let them pass and continue with their tour, only to discover that our team rounds were going to be a stop on that tour. And they'd be there long enough to hear the presentation of the next patient. Which happened to be mine.

And thus, my patient presentation (on absolutely no sleep) was suddenly not only for my team, not only to my senior resident, not only in front of the chief resident, but also would serve as a "model Metro patient presentation" for a group of applicants (none of whom I happened to know personally, though they are all my educational peers). To add to the mix, not only do I have the desire to give an excellent presentation through the "fog of post-call", but my senior has the goal of showing the education that occurs on senior rounds ... which practically necessitates highlighting what I *don't* know so he can teach it to me. Lucky for him, the realm of what I don't know is quite expansive.

Much of the steep learning curve in medicine is not the actual medicine itself, but the tangential aspects. Should this patient get a regular diet, or a soft diet, or a renal diet, or a low-sodium diet? Do I have to order a bed-side commode, or can I just ask nursing to find one for me? How do I write out an insulin sliding scale order as to avoid using forbidden marks (< and >) and yet ensure that nursing and pharmacy both understand what I want?

These are actually easy questions (at least, they are easy targets for ridicule when done wrongly), but we aren't ever formally taught how to answer them. In fact, many of them vary by the cultural of the hospital: Do I give NS, 1/2 NS, or Ringers? Who could know ... until you order the wrong one.

I would wager a guess that most people would prefer that their interns and residents not learn by trial and error (aka, "practicing" medicine). However, the truth to the matter is quite the opposite ....

Current Mood: tired. very, very tired

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