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On scraps of paper, in the middle of the night: Interns and residents teach valuable lessons

No matter how busy they are, Stanford interns and residents often stop for teachable moments, and medical students are grateful, writes Orly Farber.

It was 9:30 p.m., and my internal medicine team was swamped.

The team room was boiling hot, and it smelled of the popcorn and chips we had eaten for dinner. The senior resident was on the phone, trying to arrange for a patient's urgent procedure. One intern typed furiously. The other rubbed her temples as she stared at a stack of papers muttering, "What was I just about to do..." 

We'd gotten several new admissions from the emergency department in the evening, and we had just wrapped up seeing each new patient, asking about their history and examining them. Now, we needed to finish documenting all of the information and, more importantly, finish placing orders for medications, labs and nursing tasks.

I opened up one patient's chart on my computer and saw his updated lab results. I read the liver enzyme results out loud; he showed signs of tissue damage or inflammation. The muttering intern looked up. She was clearly exhausted from the day -- or from the last three weeks she'd spent working long hours, caring for complicated patients on the wards.

Nonetheless she smiled at me warmly. "Let's talk about the differential," she said. Then she launched into a mini-lesson about how to interpret the abnormal lab values, talking through all the possible causes of liver damage in our patient. 

These kinds of moments are common on my clinical rotations -- interns and residents, who are themselves junior doctors still in training, halting their work to explain or instruct.

Sometimes, the lessons cover technical skills. On my surgery rotation, one intern built a fake set of ribs out of plastic tubing to teach me how to place chest tubes. On OB/GYN, just before my patient gave birth, a resident pulled out a plastic pelvis and baby-sized doll to remind me of the steps involved in delivery. 

Most often, the lessons help refine my thought process -- teaching me how to determine the most likely diagnoses, or how to think through the first steps of a treatment plan. Residents give impromptu lectures or use a more Socratic approach, questioning me on topics ranging from the possible causes of low sodium levels in the blood to the initial steps in treating heart failure.

My most unexpected lesson came from a plastic surgery resident I consulted while on my emergency medicine rotation. After he evaluated my patient, he asked if I wanted to learn about a completely different topic: intravenous fluid resuscitation, or the different types of fluids given through an IV when a patient is acutely ill. He grabbed a paper towel and drew a handful of charts that I still reference many months later. It was 1 a.m., and he wasn't even assigned to teach me. 

Though I learned a lot from faculty lectures during my pre-clinical years and I continue to learn from the attendings I now rotate with, nothing compares to the one-on-one training I receive from these interns and residents.

They teach with enthusiasm during a workday that, from my vantage point, looks difficult and draining beyond belief. They juggle dozens of tasks that, by and large, few doctors really love -- paperwork, care coordination and answering relentless pages. They work incessantly (albeit under a legal hourly cap of 80 hours per week), and they're sorely underpaid. On average, residents make between $50,000 and $80,000 per year. However, according to the book An American Sickness, the value of each resident's work is $232,726 annually.

In the middle of the winter, at a time when interns are known to begin feeling burned out, I want to tell them how much we appreciate them. I want them to know that my classmates and I are endlessly grateful for their willingness to teach -- on their best and worst days, on scraps of paper, while walking to the cafeteria, in the middle of the ED in the middle of the night. 

There are lots of ways medical students can show our gratitude even when we, ourselves, are a little worn out. I'm typing this while baking treats for my intern's birthday, for example. We also can nominate our team members for awards or simply write a quick note to thank them at the end of rotations.

In 16 months, when I become an intern myself, I want to show medical students the same enthusiasm for learning and kindness that others have shown me. I intend to teach it forward, and to keep paper towels and a pen handy. 

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

Orly Farber is an undifferentiated third-year medical student from the East Coast. She loves reading and writing about medicine. Her written work has been featured online in STAT News and The Intima, as well as in print in The Boston Globe. In between hospital shifts, you can find Orly running The Dish or making a mess of dishes in her kitchen.

Photo by Orly Farber

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