A Day in the Life

What is a day in the life like for an intern or senior resident at the University of Michigan? A few of our residents give us a glimpse into a typical day.

Meet Virginia Sheffield, MD, Internal Medicine Senior Resident
Class of 2020

U-M Residency Program, Virginia Sheffield, MD
Virginia Sheffield, MD

Early in the Year  On Inpatient VA Rotation

A typical call day starts with my first alarm set for 5:45 am (I am generally feeling ambitious the night before), with the second alarm set for 6:00 am. I scramble to get dressed in the dark (scrubs on a call day and business casual on a non-call day). I peek in at my angelic, sleeping toddler and then tiptoe out of the room trying not to wake him (at which point he would become most assuredly not-angelic). I head to the hospital (10-minute drive) with two cups of coffee in hand (one for the road and one for the team room), getting in around 6:30 - 6:40 am.

When I first get in, I check with the interns to see if anything major happened overnight and whether there are actively ill patients that need to be evaluated urgently. On early call days, there are one to three overnight admissions and I will get the brief story from the night admitting senior and then read about them in CPRS. I then go through all of the patient's labs and consult notes from the previous day and think through any changes to the plan. Prior to rounds, which start between 8:00 – 9:00 am, I will run the list with the interns and make sure we are on the same page and also field questions/practice presentations from the medical students.

During the day, I coordinate with interns and assist with whatever daily tasks I can help with to keep the work flow going (offer to call a consult, put in orders, supervise procedures). I triage and accept admissions from the ED and generally see them after getting their story, leaving most of the history taking to the intern. I try to make it to morning report every weekday at 11:00 am and to the noon conference on Mondays and Wednesdays. Ideally, there will be time throughout the day for a quick chalk talk with the medical students. I inevitably end up making a trip to the famous patriot store which is full of candy and electronics.

While the work load and hours can be exhausting, the saving grace (and my favorite thing about training here) is the team. On the busiest, craziest, longest call days, when sad things happen and everyone feels overwhelmed, I am always able to appreciate the people I am surrounded by. There is no shortage of goofiness, chocolate, passion, laughter, and true desire to help and support each other. I always feel like I have someone to bounce ideas off of (co-senior, attending, fellows) when I am unsure of the optimal plan and I never feel alone.

Before I leave for the day, I always check in with the interns and make sure we accomplished all of our tasks. I make sure that any calls to family members have been made and discussions with patients have happened and also go through my list to make sure all of the to-do boxes have been checked.

After work, I rush home to try to see my little guy before he goes to sleep. I then cook dinner with my husband (or, let's be honest, just eat the dinner that he already cooked), and curl up on the couch with my two pups for some relaxing and unwinding at the end of the day. On early days off, the whole family makes it out to our local restaurant/brewery for dinner, beer, and trivia.

Meet Christian K. Alch, MD, Internal Medicine Resident
Class of 2021

U-M Residency Program, Christian Alch, MD
Christian K. Alch, MD

It was only a few months ago that I was an MS4 nearing the transition into the next phase of life, beginning my residency in Internal Medicine. Periodic waves of excitement overwhelmed by feelings of inadequacy and underpreparedness. Even now I can look back and say that there really is no way to prepare for Intern Year; you can only experience it for yourself, and that is okay. Far more than the well-published physical demands of duty hours and heavy workloads, there are emotional demands of entering into the doctor-patient relationship for the first time that will transform you in ways you don’t expect. You will find friends to laugh with, colleagues to learn from, and shoulders to cry on; for these reasons and more, I can’t imagine a better program for me than the University of Michigan.

During in-patient rotations, my morning begins around 5:15 am, where I am ushered into my day with a brief chart round on Epic and a delicious, balanced breakfast (shout out to the better half). There is often an H&P to read over before leaving for campus - you’ll receive the full presentation from the resident later, but having at least a superficial understanding of your admissions can help smooth things over during busy mornings. The night team will update you on the overnight events, give you the story on the new patients, your pager will be signed over, and “now my watch begins”.

The period between sign out and rounds is one of the busier parts of the day, and when you come in with a full list (eight patients for interns), efficiency is paramount. My next stop is straight to the patient rooms. If any of the patients under my care are acutely worsening, I like to have my senior prepared earlier rather than later in the morning. Rounds start at 8:30, where you will be joined by a talented group of medical students, pharmacy students, a pharmacist, your co-intern, senior, and faculty. Rounds prioritize acutely ill patients and patients being discharged, otherwise, you start at the higher floors and work your way down.

One of my seniors gave me a “workflow” for the day that I find works well, C-O-P-S-L. First come the consults: I try to get them cooking early (8:00 am), and if they can be cancelled later, no harm done. Next come orders: you will be placing them as interns, and some will be urgent enough that you’ll need to break off from rounds to get them done (that’s okay now, you don’t have to go to every patient room!). Progress notes come next: I try to get them finished soon after rounds, with other updates going into my sign out. The afternoon is typically a balance of following up on labs, hearing from your consultants, and putting in discharge summaries. Additionally, you may get to sit in on a teaching from your senior or faculty to the medical students (which are always overflowing with information I need to learn as well!).

Sign out at night can be one of the more difficult adjustments to residency. Many new interns (like myself) had never done sign out before and it takes practice, practice, practice. When you take on cross-cover patients for the first time, you will appreciate how important clear anticipatory instruction can be. I’ll update my sign out periodically with key events during the day before completing it at the end of my shift. Finally, the last step is to check the labs and get them prepared for the next day; no one likes chart reviewing on patients without labs in the morning. In the words of Sir William Osler, “The best preparation for tomorrow is to do today’s work superbly well.”

The day to day workflow can be exhausting, but it is also supremely rewarding, and I feel so thankful to be playing this role in my patient’s lives. For the first time, it will be you who will be performing procedures, responding to pages, and talking with families. Never forget what brought you to this stage, and when you feel your battery is running on empty, be comforted that you will be surrounded by wonderful people who want only the best for you.

Meet Rachel Hechtman, MD, Internal Medicine Resident
Class of 2021

U-M Residency Program, Rachel Hechtman, MD
Rachel Hechtman, MD

Early Call Day at the VA – September Intern Year

5:20 am – Alarm goes off. Snooze. Why even bother with that first alarm?

5:25 am – Second alarm. Get up, wash, throw on scrubs. Thank god for scrubs.

5:50 am – Out the door. Listen to The Curbsiders podcast on the way to work. Topic today: Heart Failure Guidelines. Why is it that I have to hear these recommendations so many times before they stick?

6:00 am – Arrive at the VA. Appreciate the unanticipated intern year joy of easy parking at 6:00 am. Get sign out from overnight team. Everyone had a pretty quiet night. Hear about two new overnight admissions, bringing my service up to 6 patients: one with heart failure (I should know about this now!) and one with hepatic encephalopathy. Love the variety of Gen Med at the VA.

6:30 am – Do chart review on what labs have come back so far. Pre-round on my new and old patients. Tell Mr. H about the results of his MRI. Remind Mr. R to watch his fluid intake today. Shake my head at the fact that Mr. P feels compelled to tell me the same jokes every morning. Touch base with overnight nurses to get the real scoop on how everyone did. Visit my two new patients. Check on their understanding of the plan thus far.

7:45 am – Finish chart review. Most AM labs have resulted. Ms. K is hyponatremic. Can’t think of an obvious reason, so call the lab to add on serum osm. Add urine studies. Sit wondering if this was a good idea or if I’m missing something. Make my one page rounding/daily to-do list. Still experimenting with the best way to keep track of everything for the day.

8:00 am – Attending arrives. We discuss the overnight admissions and then go round on everyone. Great discussion on the differential and workup for new arrhythmia during rounds.

10:30 am – Finish rounds. Time to complete my carefully constructed checklist for the day. Immediately realize I got distracted on rounds and forgot to write some things down. Try to reconstruct. Run the list with my senior. Get a page about someone’s diet order. Don’t get distracted – put in consults for the day first. Call Mr. R’s nurse to tell him the IV Lasix order is in.

10:46 am – Wow, am I hungry. Why didn’t I eat breakfast?!?

11:00 am – Work on discharge paperwork for Mr. H. Review his medications with the incredible inpatient pharmacist who notices that he’s needed potassium supplementation every day and maybe he should go home with a new prescription? Great catch, thank you. I should have noticed that. Time to write notes. Maybe today will be the day I finish these in reasonable time.

12:30 pm – Intern report. And free food - thank you!

1:00 pm – Paged out of intern report to see a new admission.

2:00 pm – Finish reading about and meeting new patient. Do medication reconciliation. Order inpatient meds. Forget to ask code status. Walk back over to ask code status. Back to writing notes.

3:30 pm – Still writing notes.

4:30 pm – Receive page: Mr P’s family has questions. Hooray, note break. Sit down with them to help explain. Leave the room to smiles. Feel useful.

5:00 pm – Two more notes to write. Then need to write sign out.

6:00 pm – Don’t forget to put in labs for tomorrow morning! Does Mr. R really need a CBC every day, hmm?

7:30 pm – Sign out, leave the hospital. Hey, I might have time to go to the gym! Immediately think of 4-12 reasons not to go to the gym. Drive home and rewind the same Curbsiders podcast because I can’t for the life of me remember what they said this morning about when it’s okay to give amlodipine.

7:50 pm – Home to find the most incredible husband in the world is making tacos. Feel so happy I could weep.

8:30 pm – After dinner, clean up. Sit on the couch with laptop to finally look at the 40 emails that built up over the day, then poke around the internet for a few minutes.

10:20 pm – Oh dear, how did it get to be so late?! This is unsustainable. Must learn to go to bed at a reasonable time like an adult. Feel guilty. Tell myself to stop feeling guilty and go to bed, for heaven’s sake.

11:00 pm – Actually sleep.

 

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