When I was a resident, I wanted to be a great chief and team leader. I wrote a set of guidelines for my interns to let them know how they could excel on my surgery service. Years later, an orthopedic surgeon who was once my intern told me about the impression these rules made on her. She still shares this document with her teams.
You can download the original Rules printout to share with your team, or keep reading to find out how to be a great surgery intern.
Intern rules by Erin
Be on time. Be responsible. Be honest.
If you don’t know, ask.
Know your patients. Know their numbers too, but remember the computer is not the patient.
Develop a system for tracking to-do items. I don’t care what it is, but miss nothing.
Be resourceful. Solve problems yourself if you can. If you can’t, bump it up.
Listen carefully and take notes. Your chiefs and attendings use specific language for you to reproduce in orders, notes, and op reports. If you don’t understand, ask for clarification. Do not assume your generalization will suffice.
Communicate often. If we are in the OR, come talk to us in person. Calls into the OR are annoying.
When you’re not too busy, come to the OR to learn. You are always welcome.
Your notes are a form of communication with your colleagues. Take pride in them, as they reflect your knowledge and professionalism.
Be clear and be brief. This applies to notes and presentations. On floor rounds, you will look good if you know more than you tell me.
Anticipate dressing changes on rounds. Have supplies.
Interns should take initiative to address details that are routine but nonetheless essential to good care. My interns should feel empowered to independently:
- Give all patients SC heparin unless there is a good reason not to (e.g. brain bleed).
- Give all patients on PO narcotics a stool softener unless there is a good reason not to (e.g. patient has diarrhea, or no colon).
- Give patients their home meds unless there is a good reason not to (e.g. metformin).
- Replace electrolytes and order labs when indicated. However…
More studies does not equal better care. Do not order labs or imaging unless the results will change your management.
Again, if you don’t know, ask.
As my chief once said to me, “I am here to make you look good.” If you work hard and keep me informed, I will back you up and make you look good.
In turn, you should back up your teammates. Especially your students. Make them look good.
Keep reading for part 2, a detailed guide for medical students. Follow this guide to give an excellent patient presentation on surgical rounds.
How to present on rounds
This is the format I like for medical students. Interns are not expected to examine patients before rounds, so you will mainly tell me events and numbers.
Please be brief. Students have about 3 minutes of my attention. Interns have about 1 minute if rounds are leisurely.
ID: (Age) (man / woman) post op day # ___ status post (operation) for (diagnosis)
Events: Overnight only! Not the whole story. Most patients will have “no acute events.”
Subjective: Pain / nausea / flatus / dizziness / etc? Include pertinent positives and negatives.
Vitals: For more advanced trainees, “AVSS” is sufficient because I trust you will recognize and report anything abnormal. For most students and new interns, I expect ranges for the past 24 hours reported in the customary order (below). If the range is abnormal, please tell me 1) when the abnormal number happened and 2) what the current number is.
- Tmax (not a range)
- Heart rate
- Blood pressure (SBP range / DBP range)
- O2 saturation, on (what kind of supplemental oxygen)
- Ins and Outs:
- Total In / Total Out
- Pertinent individual Ins (especially PO)
- Pertinent individual outs (urine, each drain individually, stoma)
- Blood glucose range if applicable
Physical exam: Brief and focused. Normal patients are “lying comfortably in bed, appropriate and interactive.” A normal post-operative abdomen is “soft, non-distended, and appropriately tender.” Normal incisions are “clean, dry and intact.”
Lab results: This morning’s labs only. I will be impressed if you can tell me only the ones I care about. Alternatively, quickly read all results in the customary order.
Assessment: Do not repeat everything you just told me! My assessments are often “Doing well after surgery” or “Progressing as expected POD1.”
Plan: Make your best guess. Going by system may help in complex patients but not in simple ones. Might want to review meds and ask yourself whether these should continue / start / stop (e.g. PCA, antibiotics, insulin, DVT ppx). Think about meeting the following milestones for discharge and what needs to happen to achieve them if not met yet:
- Eating
- Walking
- Voiding
- Pain well-controlled
- Not on IV medications