After the long journey that is intern year, you have now arrived. The 1st day of your 2nd year of residency you are no longer the most dangerous person in the hospital.

Congratulations.

However… with great power comes great responsibility.

As a junior resident, you are in a unique “balancing act”. You will be the closest to all the interns, but still somewhat far-removed from the attending, which is usually reserved for upper-level residents, chief residents, and fellows. There are a few things you need to be aware of:

You can no longer say “I don’t know.”

As a junior resident, it is unacceptable to “not know”. If you don’t know something you have the base knowledge and experience provided from intern year to be able to find the answer relatively quickly. Your new go-to answer if you don’t know something is, “I think I know the answer, but let me look it up to make sure.” Do not simply give an answer if you are not sure about it. And not all answers are so simple. Just searching up-to-date may not be enough. You may need to look at the recent articles in your specialty’s journal to get a better perspective.

Your intern(s) will rely on you.

Don’t be a spreader of black pearls. If you tell one intern the wrong answer to a question they have, your answer will spread throughout the rest of the intern class as true because it is from a “senior resident”.  You need to take responsibility for your answers, and also for the education of those less experienced than you. Remember the senior resident who you looked up to the most and try to be like him/her. Medicine is a constantly evolving practice of teaching those who come after us about our experiences, triumphs, and mistakes.

A colleague of mine uses the term “golden nuggets” to describe these high-yield pertinent tidbits of information. An interesting thing about these “golden nuggets” is that they are so, so important that senior residents, fellows, and attendings often forget that they aren’t common knowledge.

For example:

In radiology, an attending shows you your first head CT and says, “This one is easy, take a look at this case over there and let me know when you see it.” You sit at the monitor sweating, scrolling up and down for 20 minutes and you DON’T SEE ANYTHING WRONG. Defeated, you walk over to the attending and tell him/her that you don’t see the abnormality. Surprised, he/she says “Really? It’s right there, pointing at the subdural hemorrhage” on his screen, clear as day. You swear that wasn’t there on your screen, you had literally looked at every damn pixel on every image for 20 minutes… How could you have possibly missed it?

You walk back to your station, depressed, wondering if you were blind. Sitting down again, you scroll to the same image that the attending showed you… and… YOU STILL DON’T SEE IT.

Now you think to yourself that you are going crazy… until a radiology resident walks over to your station and says “Hey dude, looking at your first head CT?” Sheepishly you say, “Yea… but I don’t see the bleed.” The resident calmly says, “Oh man, you’re never gonna see a subdural on THAT window.” He moves the mouse to the right, holding down one of the buttons, and all of the sudden the subdural hemorrhage jumps out at you and hits you over the head with a hammer. “How’d you do that?” you cry. “That’s called the window-level,” he responds. “You need to use different window-level settings to optimize looking at different things, like stroke versus hemorrhage, or evaluating the bones versus soft tissue, etc.”

This is what I mean.

This is so simple, but without this crucial piece of information, how could you ever be expected to get the right answer? The senior residents, fellows, and attendings are so far-removed from the novice level that they forgot that this information isn’t common knowledge. There are “golden nuggets” like this in every specialty of course. Try to make it a point as an intern to remember the “golden nuggets” you were taught so you can teach your intern(s).

Prioritize what you teach your interns.

Is it really all that important for them to calculate acid-base balance in their heads on day 1? How about just teaching them “the ropes” first. Before they can be good doctors, they need to be able to learn day-to-day functioning of the hospital and be as efficient as possible. You have the experience and they need it. Tell them what you did as an intern, what worked and what didn’t. When should they come in to start pre-rounding? What is the best time to “grab lunch”? What is a good “sign out strategy”? What is the most efficient way to take notes and write a note? etc. etc.

An uncommon presentation of a common disease is probably still more likely than the textbook presentation of an uncommon disease.

It’s not always going to be Familial Mediterranean Fever or Erdheim-Chester disease. Don’t lose the forest in the trees. When you hear hoof-beats it’s probably a horse, not a zebra.

Full disclosure: I actually have had patients with both of these diseases.

But sometimes… it is…

However, you will see some zebras in your life, maybe even a few unicorns.

Remember them. Burn them into your memory. As unlikely as it they be, sometimes nothing else fits and you need to be able to pull out these zebras from the depths of your memory in order to really help the patient.

Don’t be afraid to ask for help still.

There is still always some one more senior than you. An upper-level resident, fellow, or attending. Be assertive, but also know your limitations, but also be aware of what you can contribute to the team. Someone more senior than you should not be angry at you for calling them if there is something happened that you are not equipped to handle.

TL;DR

You can’t say “I don’t know” anymore. It is your responsibility to know… and if you don’t, go find out.

Give your intern(s) “golden nuggets”.

When you hear hoof-beats, it’s probably a horse….

…. Except when it’s a zebra… or even a unicorn.

Be assertive, but know your limitations.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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