#pdtn does intern year

[pleasedotheneedful]

I wrote an order for 120ml of McDonald's Cold Brew coffee PRN through his NG tube, but not before 1400. It's the best order I've ever written. Some people don't like it, but hey, I'm not going to be the one denying a dying man his daily coffee.

R3

[pleasedotheneedful]

I’m only 2.5 months into residency and I’m about to burn out.

I felt I couldn’t keep up with my peers or the demands of work, and every day this week someone has given me the feedback to back it up. I come home sobbing for hours afterwards, and then the cycle self-perpetuates because I’m supposed to answer questions on rounds on a topic I didn’t research because I was too busy sobbing the night before. I was told I seemed to lack the curiosity about my patients’ conditions.

It’s true. I used to come home and start doing directed research, now I just come home and cry. If I’m lucky I manage to make dinner and watch TV. I got some rare yoga sessions in but I haven’t run or lifted in months. I’m just sort of going through the motions.

What’s worse is that I feel I can’t go to my leadership about anything like this because people talk. And I have no friends outside of the hospital so I lack the support I did at home. I swear every day I wonder if I bit off more than I could chew by moving here.

[pleasedotheneedful]

Intern year, T+82

Uh, well, I'm in the ED.

My own ED. As a patient. All of this pissing and moaning finally came to a head last night when I woke up with this intense sadness that spiraled into yet another episode of intractible, inconsolable crying. I asked one of my cointerns to bring me in but I got transiently better when she came over with a care bag and shot the shit with me for a while.

She also agreed to work a couple of my shifts so I emailed one of my chiefs, who sniffed out something was wrong when I asked for time off and so I told him what's been happening. They asked me to come here for a psych eval and now I'm here sitting in the exact same chair I was in last month, reassuring a young soldier that I know how it feels to not have your pain validated. I knew too well.

For what it's worth, I am doing okay but I didn't start experiencing relief until my fiancee first suggested I go get an eval. My leadership is now tracking hard on this and I am hoping I get the help I need.

[pleasedotheneedful]

Intern year, T+88

Well, I had written a post on Saturday but I guess tumblr mobile ate it. Also, long post warning.

I am going to be frank, because I think this is important. I had my night float shift last Thursday, and Friday I woke up feeling horrendous. Just incredibly down and depressed. I know I’ve had a rough time recently but usually I start the day in reasonably good spirits.

Probably a circadian dysrhythm contribution, but this was pretty bad. I had talked to @doctor-dumplings for a while and was just unable to shake the feeling. The previous night’s shift wasn’t necessarily that bad, or at least my feedback was very encouraging save for being prepared to sign out new patients to the day shift. I still didn’t want to go in the next night, and the anxiety of my program keeping me on a short leash was actively crushing me. Eventually I just reverted into this inconsolable sobbing to the point where she asked if I maybe considered going to the ED for a psych eval.

As soon as she said that a weight came off of me. I mean, for two months I’ve felt this building weight on me and along the way I’ve lost interest, energy, concentration, appetite, and had these intensified feelings of guilt/inferiority. When she said that I acknowledged that maybe I have a real problem that requires immediate intervention.

So I called one of my co-interns asking if she’d drive me to the ED. She came over with a bag of junk food and beers and we just shot the shit until 3am. I felt better, but I knew I needed a couple of days. In asking my chief for sick leave, that’s when leadership caught wind that something was wrong.

Next thing I know they arrange for me to come into the ED to see the psych resident on call. The same ED I just spent a month working in, triaged by the same teams I coordinated orders with. I think the most fucked up thing is being placed in the psych room where I had just told a young soldier that I understood how it felt to have your feelings of depression invalidated by people close to you. I told him that at the beginning of my downfall, when I had tried to bring up problems I was having with that ED attending to my leadership that were basically dismissed. It was the beginning of my downfall and I had come full circle.

I was deemed not a risk to myself or others, and discharged with follow-up to a psychiatry attending in-house today. One of my other co-interns picked me up and we hung out in a small group. It was a nice relief.

Today, I was asked to meet with my leadership staff before my appointment with psychiatry. They opened by informing me that I was formally placed on a remedial status. Functionally this wasn’t supposed to change much, I was going to be kept under a close eye and working tightly with a senior resident. But now it’s documented. This could have difficult implications on my interest in changing programs/specialties. We then went over some schedule changes and I was told they would “try to keep [my wedding] in mind as they rearranged things” and that I was going to work night float for my final block instead. This is the block in which I was supposed to attend @doctor-dumplings graduation, and when I informed them of that they told me we would cross that bridge later. I came away from the meeting pretty disappointed--this all still felt punitive. I met with the psychiatrist who simply listened to my problems for two hours and helped me see that I still had a lot of options to explore, and encouraged me to discuss some of my concerns with the program re: staying in it or switching specialties.

My leadership then met with me again afterwards, and this meeting was a little more receptive/let me know they were concerned for my well-being. How genuine this is, is beyond me but I took some belief in it. With encouragement from the psychiatrist I reiterated that I was unsure if this program/specialty was right for me, and said I needed some time to discuss everything with friends/family/colleagues.

So where are things at right now for me?

I’m off rotation this week, instead I’m attending the retreat and doing the FCCS course. I have no idea what the plan is for the rest of the month or what changes they’re going to make to my schedule.

My short term goal is to get some good habits going again, and reach out to residents for feedback/guidance that is far more specific. That will help me figure out if this short leash is warranted or if I’m being targeted unfairly. I reached out to my PCM about starting an SSRI. I’m going to call my folks and bring them up to speed.

I still feel guilty about all this, but at the same time I know this was inevitable and probably the best case scenario. Everything was bubbling over really fast and I couldn’t see a way out other than fantasizing about being literally anywhere doing anything else. It’s confusing because the things I love about internal medicine are the right things to love: I love being at the bedside, interacting with/teaching patients and families, coordinating with staff, calling consults, placing orders, writing notes in my style... yet this all got overshadowed by a string of feckless feedback that I couldn’t shake. I’m my biggest critic and I still struggle to see what mistakes I’ve made that are different than any other intern’s here or anywhere else.

So, alright, I guess I’m resentful too.

[pleasedotheneedful]

I like finding out through my patients that their PCM is being changed permanently, before anyone at my program has told me

also have I said how much I enjoy that the outpatient EMR crashes on a regular basis

or that I have to access a secret menu in a different EMR to see patient appointments

[pleasedotheneedful]

Welp, it’s in. I still need my transcripts and LoRs to get uploaded but the applicaitons are sent. I still have room for five free IM program applications and I’m open to suggestions.

[pleasedotheneedful]

Intern year, T+96

I met with my leadership staff today. I gave them the full rundown and my plan. I talked to my interns. I talked to my fiancee.

I know what I’m willing to accept and I know what they can give me. I’m going to prepare myself for all possibilities--that she matches here and we stay here, or that she doesn’t and I transfer out to the mainland.

Having said that: Anyone have leads on Med/Peds or IM programs that might be interested in taking me as a PGY-1 with credit or a PGY-2? I might be slightly off-cycle with the LOA, which makes this a little more complicated. I have to simultaneously open ERAS and cold call programs.

Ugh, I have to open ERAS.

[pleasedotheneedful]

Today’s the day I tell them I want three months of medical leave. I might lose my pay, and I might lose my health insurance (the latter of which is just... crazy to me). But either way it’s what I need, and I can’t let outside factors distract me from that again.

[pleasedotheneedful]

My PCM office is actually a husband and wife team, one focusing on behavioral health and the other doing acupuncture, stretch, massage, etc. Both serve as de facto sounding boards for my hatred of residency whenever I’ve been in the office.

I’ve been dropping a ton of co-pays on them but I find it’s been pretty helpful. They usually reiterate what they told me before about making sure I get out and do something on my free time, and ultimately residency is a job; they don’t own my free time. And no matter how insane and impossible their expectations are (I would honestly be surprised if the majority of my intern class came out of their second month of ICU leaving an impression that they could run the show), keep playing a good attitude and they’ll never have incentive to separate me.

Easy to forget but the reminders are helpful. Along with the medication titration and physical treatments.

And I got the go ahead to ease into lifting, but real light with detailed attention to form. And to not go below 90 degrees if I bench.

[pleasedotheneedful]

Intern year, T+82

You guys remember when I was nervous but starting to enjoy the ICU/first weeks of residency?

Seems like it was a generation ago.

I got called down to talk to the other chief and an APD about my performance in the ICU after two blocks of it. Apparently I'm still below standard and not ready to run the unit (this is my last ICU block until 2nd year), so they're mandatorily attaching me to the daily night senior for my night float block starting tomorrow. This feedback is apparently congruous among my attendings.

I just feel so defeated. I'm doing the best I goddamn can and I'm still floundering. I didn't think I did so poorly since the last run of feedback. I know I missed some pimp questions... so fucking what? I thought that was part of the learning process? If it's not that, what else am I missing? I put in the orders, write the notes, talk to my patients, explain things to their families, talk to consultants, read, improve my organization. I swear this all stemmed from that bullshit day where I ordered the wrong imaging on a patient at the end of a terrible shift where I never had time to eat or drink for like 13 hours. After that I went on the radar.

Or I'm the only IM intern this year who can't run the fucking ICU after my third month of residency, trying to figure out this whole bureaucratic piece of shit with its horrendous infrastructure.

Also I got some partial resolution on this stupid leave/contract bullshit. Everything is outline in a word doc. Still not a contract and why it took four people to point it out to me is beyond me.

I just feel like I want to be done with this so much. I feel like I'm too soft, and I made a mistake. I don't come home excited about patient care anymore, I haven't in two months. I just come home pissed off, sad, or relieved I had a slow day.

That's the only breath of air I get anymore... not having patients. Because it means no one can evaluate my incompetence.

[pleasedotheneedful]

Guys, I need to get another whiteboard solution going. My medical education is lacking without it, since I know this is how I learn on my own.

I wasn’t able to bring my three giant slates with me because they would cost an arm and a leg to ship, and I really wouldn’t have room for more than one of those in my place. I do have up to 60x40 inches (1.5x1.0 m) behind my desk I could use though. My first thought was to just slap the largest possible board up there but those are kinda pricey and I have a history of not mounting heavy things well, and I don’t want a giant falling whiteboard destroying my new desk, my laptop, or the tile floors.

I was thinking about buying a panel of smaller whiteboards and tiling them together on the wall, but I’d have to be really diligent about hanging those so they’re not individually blowing in the wind... I didn’t know if anyone had better ideas though. I heard the self-adhesive rolls are pretty terrible but I haven’t actually tried them myself. Thoughts?

[pleasedotheneedful]

“Use the ERAS 2018 token listed below to gain access to the MyERAS application.”

I still cannot believe I’m doing this again.

[pleasedotheneedful]

Intern year, T+95

okay guys I owe you an apology on behalf of the tumblr mobile app. I did not make a second trip to the ED, I had written a post while I was there the first time and the mobile app ate it and decided to spit it out two weeks later.

unless all these well wishes are because you are finding out about this for the first time in which case thank you, I appreciate it!

I am now about two weeks out from this, and I’m doing alright. I’m not currently on a rotation and taking time to get myself together/come up with a long-term plan. PCM is working closely with my anxiety/depression (let’s be real and call this what it is). I’m off the clonidine and onto the SSRI. FWIW I felt the clonidine had some merit, but wasn’t sufficiently able to help with the after-work sorrow. Also the xerostomia was unreal, which made presenting difficult.

However, coming up with a fixed long-term plan is going to be difficult as I don’t know if I intend to stay in this program or not. For me, it hinges on whether @doctor-dumplings is able to match here and that seems to change with the weather. I take great honor in being at this program and serving the people that come through our doors, but I can’t spent 2.5 years here without her, or without the rest of my support network. Not while I’m just trying to grasp being a resident. So I kind of need to cover all my bases and have a foot out the door.

There isn’t really a delineated method for residency transfers/swaps like there is for the match, so I’m kind of forging this path alone. The fact that I’m considering a 2-3 month LOA and that I’m on formal remediation complicates matters as well. I’m emailing some familiar program directors after my PCM appointment this afternoon about openings for either PGY-1 or 2 positions next fall.

And then there’s the question of, well, if I do another PGY-1 year with credit do I need to reapply through the match as a current intern? So many questions, so few resources...

[pleasedotheneedful]

Intern year, T+92

In lieu of being on a rotation, I attended the program retreat and the two-day critical care course this week.

The retreat was nice although pretty awkward for me given everything that’s happened. I spoke with a few current and former residents who assured me that the program is not trying to squeeze blood out of me, but is flawed in that residents who are perceived to be struggling [which may be entirely based on perpetuated rumors] go under micromanagement, and then actually do struggle or commit mistakes that aren’t unusual for an intern but now the tunnel vision is on you. It’s still bullshit and I don’t know how I feel about it, but I guess it’s better than being maliciously hung to dry.

The critical care course was pretty awesome though. A bunch of things that never clicked while I was on my two ICU rotations started to make sense. It sure would’ve been nice to have taken the course before my second ICU block but I don’t make the schedule.

I have to make a decision soon about whether I want to take a leave of absence, and if so for how long. I don’t really have any anxiety about graduating late, but I’m not sure taking the remainder of the academic year would be helpful. One of the past grads told me there was someone in his class who was under heavy scrutiny, ended up taking six months off to get control of her anxiety, came back and ended up being one of the best in class.

Unfortunately I think I have to figure something out sooner than later, as I am sure my leadership will be asking me to come in early this upcoming week to discuss the next steps. Or they’ll try to make them for me, which I don’t want.

[pleasedotheneedful]

nurse: When I first started here I thought "ASA" on the board was talking about aspirin, so I remember walking into this patient's room with a dose of regular old 325mg aspirin and they looked so confused.

me: Wait, it doesn't stand for aspirin?

nurse: Well, no. It stands for alleged sexual assault.

me: Holy shit. Thank you for telling me that. I thought it was indicating aspirin overdose.

[pleasedotheneedful]

Intern year, T+74

I walk into the ICU last night and we’re borrowing beds from PICU. God damnit.

So we start trying to urgently step down patients and I swear every time we got one out another came in. I stayed somewhat on top of it, but still.

Meanwhile the frustration within the program is palpable. As part of the wellness initiative, we have group therapy sessions in lieu of noon conference periodically. Despite being mandatory, attendance has been dropping off precipitously. Although it’s considered protected time, I am guessing it is because wards are a glorified slave driver for interns and they would rather spend that hour doing the 11ty social work issues that social work dumped on them so they don’t get out quite as late.

Personally, I wasn’t there because I’m on nights. I’ve been on nights for the vast majority of the scheduled sessions. I had to reschedule a doctor’s appointment (for my shoulders and for my mental health) for tomorrow because I got home from work much later than anticipated.

The infrastructure is a huge disappointment, too. The pager system went down on a Friday and SURPRISE SURPRISE it worked again on Monday. The text pager system is integral to patient care as it provides a quick directory to reach literally everyone. And, again surprise surprise, people were calling the ICU basically using us as a directory service while this was down. There’s a bunch of construction happening and it’s not supposed to be happening during night hours because patients need to sleep, and what the fuck did we hear all night? Some dickhead running power tools right above us, through the entire 2.5 hour sign out and for several hours after that.

About to walk into night 6/6 in the ICU before my 2.5 day break, then 5 day shifts, then night float.