• Edited by: Atif Zafar, MD

How to be the Best Performing Intern In Your Residency: Revealing The Secrets of Top Performers.



I have had the privilege to mentor and work with some world-class residents. There are some unique characteristics of high-performing and thriving interns, residents and fellows. This article will allow you to learn and apply those skills.


Before we delve in. It is critical you approach the next 30 minutes actively rather than passively reading through this. The best thing you can do is to pick one characteristic at a time and apply it consistently for two weeks, by being purposeful in implementing it.


Here are the FIVE things you need to acquire to thrive during your residency:



1. They have a positive attitude. I will tell you, this is not easy to consistently do. Especially, in an intense training environment where you are on call and trying to survive a brutal schedule in a rather chaotic environment. If your personal life is stressful, you have kids to take care of after work. We all know it is not easy to stay positive in an adversary.


This is the most challenging task of all. But the most powerful characteristic to have if you want to be extremely successful during residency and beyond! A vibrant positive persona stands-out. Most of you, even after reading this post, won't be able to implement it.


Let me share with you an example. Let’s say you start your residency in July. You are excited to be part of the team. Two months go by. You are getting tired now. The excitement of being a resident physician is subtling down now. Just a day after your one week of night float is over. Right when you are expecting to destress, you get a call from your chief resident or an email from your program director, that your colleague on call for tonight’s shift has got COVID. And they would like you to come in as a backup. Huh.


Welcome to residency!


More than 90% of the interns or residents will not be able to handle this situation well. Eventually, the majority of them will end up coming in, a few will find a way to negotiate or sneak their way out, but there are these 2% of the interns or residents who will say, “ Sure, I understand that our program needs me in this desperate situation. I’ll be there tonight”. They come in and get this out of the way.



Program directors crave for these types of trainees. These interns who are able to maintain a positive posture during tough times, who are strong enough to tackle these fluctuating pressure situations with grace, are solid enough to compensate for the few “weaker” residents that the program has hired, and are pleasantly and positively taking this experience as part of the learning experience. These interns are successful, always. These interns are the ones who are offered positions to stay as faculty and even if you circle back 5 years later, the program would create a position for you. Plus you get very strong letters of recommendations, which matter a lot for folks interested in competitive fellowships and positions.



2. Smart residents have empathy & great insight. Smart residents understand how nurses, patients and families think. Many interns see their reputation and performance metrics go down in front of their eyes during the first year of residency. Smart interns resiliently tackle the pressures of residency training. They understand that nurses see interns come and go every year. The nurses see interns grow up into senior residents and then graduate into full independently practicing physicians. People like you are passing through into senior years, year after year.



Smart interns understand that maintaining great relationships with nurses is critical for their professional growth. I am using the word nurses here, but consider including allied healthcare workers such as therapists, techs, pharmacists. Physicians along with nurses and other allied healthcare workers form a team. As a trainee you need to rapidly adjust to this idea. That there are non-physicians in your team who are as smart as you are, and sometimes smarter, and they may have an exceptional knowledge base which you can use to your advantage. They also make sure they make the nurses feel safe while taking care of the mutual patients. As a physician, tylenol for pain or docusate and senna for constipation, and seroquel or haldol for delirium may not be a big deal while covering for acute crashing patients in the emergency room, but for the nursing teams as our frontline soldiers, those issues are of significance. Smart interns know how to respond to the nursing page by saying, “Hey Tasha, I got your page and Ill try to put the constipation order set in a bit. I am in the middle of an emergency consultation that may take a while. As soon as I am done, Ill put the order in. Is that okay?”. Compared to an ordinary intern who would ignore the tylenol or constipation pager by their floor nurse often for hours. Many programs have streamlined this issue by creating predetermined protocols, but I shared this example to educate you, that empathy is a very sophisticated word. Having empathy for nursing or pharmacy means you understand that something they are passionate about, care so much about, may not be as critical for you in that moment, but as a smart resident, you understand where they are coming from. Hence, you handle the situation and tackle the circumstances better than most.


Long story short, nurses are sensitive to condescending behavior by the new interns. They adore interns who respect nursing colleagues, and those who understand their nursing roles. Nursing is not easy. Handling patients who can be confused or can need a lot of care can be overwhelming. Having a pleasant and positive intern who knows how to make others feel that “we are in the same team fighting the same enemy (disease)” can be transformational for everyone around.



3. When faculty/staff say something or ask for something to be done, smart interns write it down and will make that HAPPEN. During rounds faculty or fellows can say 3 different things on 3 different occasions for the same exact patient - confusing, huh?



Often after table rounds, they will advise the team to get an MRI, but after going in the room and chatting with the patient/family, they say let's get a CT scan and lab such as LFTs, instead. A great intern would make sure they clarify the final task and make sure it is optimally followed through till the end. The MRI plan was discussed but eventually the team decided to get a CT abdomen and LFTs → all orders placed and coordinated. By the evening tests are scheduled so that for the next day’s staff rounds, all tasks are ready to be reviewed.


For a faculty to go back in the EMR and check if the correct orders have been placed or missed, is an absolutely reputation-devastating thing. As someone in the trenches, I can not tell you how frequently residents make this mistake. If you want to excel as an intern, make sure you write, remember and follow up on the team lead recommendation(s) like a soldier in the army would.



4. World-class interns work on their communication skills and strategies. They are more eloquent with better communication skills and strategies compared to the month prior. They do this as they realize communication can be their USP (Unique Selling Proposition) as a trainee.


Whether it is getting the care plan through to the nurses, updating the primary team of your consultant team’s final plan, or keeping the patient and family updated about the daily or discharge plan. Communication during residency requires proactive behavior by an intern. A resident who has a tendency to be lazy - which many of us humans are lazy to the core - will tend to let go of the communication aspects of clinical care. This hampers patient care directly or indirectly, and hence will impact the interns training, reputation, and has shown to negatively impact patient outcome.



5. Solid interns grow week by week and month over month. As your faculty, we talk about you in our faculty meetings and resident evaluation sessions. An intern can start out well because of the qualities discussed above points 1-4, but if you are not showing signs of grooming during training, it hurts your reputation. As your supervisors, we take it personally as it shows that we had a smart intern who we were not able to polish further. Stagnating in your clinical and intellectual acumen can be dangerous for you as a physician.



As an intern, you do not necessarily have to read obsessively as a nerd like you did in medical school. But every day as you care for sick patients and discuss cases during rounds, in clinics or perform procedures in the OR, it is imperative to spend a few minutes reviewing pubmed or other resources to get your knowledge base and skillset updated. Learning the latest evidence based approach is key. Maybe you assisted in a procedure and followed it up by reading on it. That is when things will stick to your brain.


One simple tip I give to my residents and fellows is to quickly pubmed a relevant issue you encountered clinically that day. This will take less than 5 minutes. For example, you saw a diabetic patient with a toe infection. You go to pubmed. You type in ‘diagnostic criteria for cellulitis versus osteomyelitis in diabetic patients’. Or you type, ‘antibiotics in diabetic foot infection’. Press search.





You will see a long list of publications show up in the search list. Next, glance through the titles and see if one of them is relevant to the case you are handling Click to open a link from the search list. That link should be from a mainstream journal of your field of interest such as JAMA or Lancet or NEJM - but there are dozens within your field of specialization. And try something recent, ideally within the last 3-4 years. For example, for the search above, I feel #7 would be a great one to review: Top journal, recent publication from 2021, and very particular to this diabetic foot infection patient we are seeing in the ER today.





Click it. The abstract section will open up. This page pops up.




Then read the conclusion, and if possible the result section of the abstract that opens up. See below.




For the above piece, we learn that 3 weeks duration versus 6 weeks duration of ABx does not matter as much. No statistical significance was found in either. It does not change your practice but makes you wonder, do I need to expose patients to such a long course if a recent study didn't even show any real benefit?


If you don't find this information VALUABLE and juicy - meaning relevant to our particular patient’s care. Consider going back to the main search page, and then clicking on another title. Or you can change the search term to more specific such as flouroquinolones in diabetic foot infection? You know where we are going here? We want to upgrade our clinically relevant knowledge using evidence based data available on our fingertips.


This will help you learn something new from at least 2-3 cases a day.


Probably 5 minutes is all it will take to glance through and extract relevant juicy information to enhance your clinical approach. If time permits, on a later day or time, you may read the entire manuscript or an Uptodate or Epocrates on that topic. As you will experience, doing the latter is challending to do on a consistent basis, but what I shared above is very easy and doable way to continue to grow as a clinician.



That is all I have for you today. If you apply what I have shared above, I promise you will excel. I have won various awards and nominations myself and have mentored some exceptional residents and fellows who experienced the same. Hence, I am recommending this with great confidence: You Must Try This Out. Pick point#1 and practice it in your internship life for the next 1-2 weeks, purposefully thinking about it and applying it during work hours. Then week 3, try point#2. This way in the first 2-3 months of your residency, you will apply all the 5 points mentioned above. By the end of the first quarter, when you get your first detailed feedback from your mentor or PD, you will be amazed on what these 5 things can do to your career. Your welcome!


Please share it with your colleagues or juniors if you think you found these valuable during your intense residency journey.


To you and to an incredible year of internship!


 

Atif Zafar, MD is the author of the book, “Why Doctors Need To Be Leaders”, and a physician leader practicing both in the US and Canadian healthcare systems. He has mentored dozens of exceptionally smart minds and helped them navigate the cumbersome and competitive environment in the field of medicine. This article is dedicated to his amazing mentees who are thriving in their careers all across the globe.


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