Surviving the First Month as a Doctor: Advice from the Community

Welcome new doctors! Yesterday you were medical students and today you are physicians! What a scary feeling. Remember that everyone shares similar concerns and fears as they start their residency and wants to succeed. Getting into residency is the beginning of an incredible journey. Savor it, relax, enjoy the ride, and be open to learn, grow, improve, and become the best doctor you can be.

Each year, NEJM Resident 360 hosts a very popular discussion on Surviving the First Month as a Doctor that includes medical students, residents, fellows, attendings, and program directors from around the world. In this post, I draw from these discussions to provide advice and answers to questions that likely are on the minds of new physicians beginning residency this year.

The following are some approaches that I wish I had utilized more during my first month of residency:

1. Ask questions: I would have benefited from asking more questions and understanding that there are no stupid questions. Other residents likely have the same question but are reluctant or afraid to ask. Remember, as doctors, we are the patient's best advocate and must use our voices to improve their lives.

2. Ask for help: I kept reminding myself that asking for help is not a sign of weakness. Patients have trusted us with their health, so it’s better to ask than to make a mistake. Ask for help when you know you need it and when you are not sure if you need it. Taking care of a critically ill patient can be quite challenging, especially early in training. Keep in mind that no one expects you to have all the answers. Don't be afraid to admit that you need help and call for back up when necessary, even when asking for help means waking up senior residents or attendings.

3. Establish open communication: It is better for patient care to have open communication with the team from the start. The more you communicate on a routine basis, the easier it will be to bring up questions and concerns as they arise. Include patients and families in your lines of communication. Keeping everyone on the team up to date on the plan of care will empower patients, move care forward, and help you anticipate issues before they arise.

4. Get to know other members of the care team: I found it helpful to include input from nurses, social workers, pharmacists, and others support team members regarding my patients. These team members are great first-line resources for patient care and have often been caring for patients and working at the hospital longer than you. The more you communicate, the more you will learn about your patients and the practical implementation of medicine.

5. Under-promise and over-deliver: I wish I had been more mindful of the time and energy it took to participate in activities or projects. If you are eager to join resident committees, start research projects, or participate in extracurriculars, you will feel better and learn more if you can fully participate in one or two activities rather than feel the pressure of overcommitting and needing to push back deadlines or bedtime.

6. Attend institutional educational conferences (e.g., morning report, grand rounds, noon lecture): Best medical practice dictates that you attend, but you will be surprised by what you can learn by just being present and by the opportunities they provide for networking and meeting colleagues.

7. Don’t reinvent the efficiency wheel: It was helpful to ask senior residents about task management tools and templates in the electronic medical record to become more efficient on the wards and in clinic.

8. Make home life easier: It was important to estimate how busy I’d be in order to prioritize my efforts. You will be busier than you have ever been. Pay attention to what matters to you outside of the hospital so you can prioritize those efforts. Automate as much of your personal administrative life as possible within your budget (e.g., auto-pay or calendar reminders for birthdays or administrative tasks). Although paying for house cleaning or grocery delivery every week may not be within your budget, using these services every few weeks or months can provide some welcomed relief. Recharging while spending time with family and friends on your one weekend day off may be more restorative than deep cleaning your bathroom or grocery shopping.

9. Take care of yourself: I wish I had known how necessary self-care is for self-preservation and to avoid burnout. You cannot take care of others if you do not take care of yourself physically, mentally, emotionally, financially, and spiritually. Stay in touch with yourself, with the activities that make you happy, and with friends and family for support. If you can, put the phone away and don’t check email so you be present as much as possible and enjoy your moments outside of the hospital without thinking about work.

10. Cultivate your professional interests: It was helpful to start early by simply observing and keeping an open mind. If you aren’t sure of a subspecialty, that’s okay. Some physicians start residency with a clear goal, many do not. Talk to senior residents and rotate on a consult service to get a sense of what you enjoy clinically.
    
    

Residency Survival Skills 

Stay Current  

• Choose at least one patient condition daily to review on PEPID, Epocrates, or UpToDate.

• Review orientation materials at least the night before starting a new rotation. Use NEJM Resident 360 Rotation Guides prior to starting a rotation for an overview of the field and to learn the relevant language and understand the major clinical problems.

• Register for table of contents (TOC) email alerts for NEJM, JAMA, and specialty journals for the most common conditions in your field of interest. Scan the headlines. Only review in depth the articles that you find interesting or are important for your patient population. 

• Subscribe to literature surveillance news alerts (e.g., NEJM Journal Watch).

• View online medical grand rounds and conferences from large medical institutions.

• Use mobile apps (e.g., QxMD), social media, and Twitter: Find trending medical news by searching hashtags (e.g., #MedEd, #MedTwitter and #FOAMed)

• Participate in journal clubs (in person or online) to gain more in-depth knowledge of practice-changing research.

• Use NEJM Resident 360 to keep up to date, participate in discussions and journal clubs, and seek advice from experts.

• Keep a record on your smart phone (or a notebook) of important clinical pearls.
  Pay attention to the differential diagnosis of the disease.

• Listen to podcasts and audio board review courses for efficiency. You can listen in your car, during exercise, or while washing dishes. Some reputable podcasts include:

  • The Curbsiders is a great internal medicine podcast featuring board certified internists who interview experts and provide clinical pearls and practice-changing knowledge.

  • NEJM Resident 360 Curbside Consults is a podcast that critically discusses practice-changing research with experts. The Curbside Consults Statistical Review series provides short primers on study design and common statistical concepts.
    
    

Develop Time-Management Skills 

You may have developed a time-management system in medical school, but now that the number of patients and demands have increased, you may need to rethink your strategy. Medical training is a marathon, not a sprint. Here are some tips to help you stay efficient:

• Try different methods early on to stay organized, find what works for you, and stick with it.

• Develop a systemto prioritize tasks. Don’t be afraid to ask your senior resident how to prioritize your tasks.

• Give yourself extra time. Know how much time you need to run through the morning routine and give yourself some extra time. You will become more efficient later in the year.

• Focus on moving patient care forward as you prioritize your tasks on the wards. Complete daily progress notes after you finished your to-do list.

• Find a task organizing template (e.g., medicine scutsheet) 
  
  

Learn Coping Skills for Challenging Rotations, Patient Death, and Poor Outcomes

Rotations can be challenging for a variety of reasons. Long hours and little sleep can be mentally exhausting. Although you may have completed a couple of overnight shifts in medical school, adapting to nighttime coverage, which can often mean several consecutive days or weeks of night shifts, can be tough. Other rotations can be challenging because you are so busy that you feel like you are constantly running from one patient to the next and putting out fires. Emotionally difficult rotations can be the most challenging. Communicating each patient’s condition with the family throughout the hospital stay is important. When the outcome is bad, make sure to let the family know how much you care and that you and your team did the best you could.

The following are some strategies to help you cope with challenging rotations or the death of a patient despite having provided excellent care:

• Prioritize sleep

• Keep a supply of healthy snacks and drinks on the ready

• Use the stairs instead of elevators for fitness

• Remind yourself that physicians before you have survived, and you can too

• Debrief with members of the care team

  • The PEARLS Debriefing Framework and Script (Promoting Excellence And Reflective Learning in Simulation) is one example of a blended approach designed to promote effective debriefing by integrating educational strategies to promote learning.

  • Share your feelings about the outcome and brainstorm, analyze, and discuss if the team could have done anything better

• Pause and take a moment for yourself to reflect on the situation; do not internalize your feelings; not dealing with your loss and your sadness is not healthy

• Seek professional counseling (e.g., Employee Assistant Program).
  
  

Turn Mistakes into Learning Opportunities

This is one of the most important things to learn as you go through medical training. The obvious goal is to never make a mistake that hurts or harms a patient. But we are human, and we all make mistakes despite our best intentions.

• Don’t criticize yourself

• Remember that residency, and particularly internship, is designed for multiple layers of oversight to catch potentially damaging mistakes. Residents, fellows, and attendings are supervising you, and nursing, clinical care partners, and pharmacy help check orders and assessments.

• When in doubt, always ask. If you are worried about a patient, unsure of a diagnosis or medication, it is best to verify.

• Understand how a mistake was made. Were there missed warning signs? Did the EMR order the wrong medication? Did a lab test not get drawn? By understanding the origin of the problem, we can prevent it from happening again.

• Debrief to help bring everyone to a common ground and lift the burden of a death, poor outcome, or mistake.

Colonel (CA) Ronit Katz, MD is the CSG State Surgeon-General. She is a Clinical Associate Professor, Medicine - Primary Care and Population Health at Stanford University Medical Center and Director of Post Deployment Health Services & Clinics for the War Related Injury and Illness Study Center (CA-WRIISC) in Palo Alto, where she treats patients and teaches the Stanford new doctors and medical students. She is Board Certified in Preventive, Occupational and Environmental Medicine, and a Fellow of the American College of Preventive Medicine.

Colonel Katz is an AMA-IMG Governing Council Member & Delegate to AMA-HOD and was selected from Stanford University Medical Center to be the Stanford-OMSS Representative to the AMA.

In 2007, Dr. Katz received The American Medical Association’s “Excellence in Medicine and Leadership Award”. In 2013, Dr Katz received the prestigious " NASA Group Achievement Award" for her role in the NASA- AMES Human Performance Centrifuge Project Team. Dr. Katz serves on many boards and committees for local and national professional organizations, including Medical Director (Act.) at Stanford University Medical Center, Judge for the AMA Research Symposium, AMA-IMG Scientific Committee, AMA-IMG Nominating Committee, Chair of the AMA-IMG Leadership Development Committee, and Chair of the AMA-IMG Governing Council.