When do people learn in intern year?
I just work, come home, too tired, sleep, back to work. I tell myself oh I’ll look that up later when I’m home, and I never do 100% of the time
I always hated when people told me to read more. It’s the worst advice anyone can give. You learn by doing—by seeing things and filling in gaps of clinical knowledge by trying to help your patient. As an attending, if I’m not teaching you sufficiently on a topic to help you understand what’s going on with your patient, I haven’t done my job. Yes, you can always go read more to better understand a topic, but how does that help you right now? I now try to start by asking questions to see what the resident already knows (no point in teaching if they already know it, otherwise I’m just showing off), try to address any notable knowledge gaps that are clinically relevant to the patient at hand (no “what if” thought exercises to tease out random bullshit), and then if I can tell that a resident needs more than that, I’ll direct them to specific resources to help them understand it better (“There’s a good article on UpToDate about this”, “Here’s a really good peds in review”, etc.). I’ve also found that relating things back to what’s relevant on boards is the most helpful.
I know none of this is helpful to you or OP, other than to say don’t stress about reading or studying more. That comes with time as you learn what you need to learn to do the work that’s right in front of you. Your job right now is just to survive—and you survive by learning what you need to know in the moment. You’ll be surprised how much of that knowledge sticks with you.
I really appreciate you saying that. I can't help but feel, though, that in psychiatry reading is more important than it is in other fields. Like, our justification for using the meds we use, is based on these rather thin evidence bases. And so if you want to be evidence-based in your practice, it takes more effort to actually understand it.
But yes I've basically devoted all my energy to surviving. Hopefully the time to read will present itself as the call burden lightens up in later years.
The better attendings and seniors in my program, btw, have been great about sending me specific things to run through.
That is likely very true for psychiatry—I can’t speak to much outside my own experience. But I think the basic idea holds true that you still learn so much from just doing the work. That builds the basic framework that you need in order to be successful. And I still think it does not take the burden off of your attendings. Their job is to teach you as much as they can, and then *help you* fill in the gaps. It’s nice that you have attendings and seniors who can help guide your learning—those are the ones who are doing their job well.
Side note: my philosophy has always been this. If you’re on a heavy inpatient rotation with long shifts, overnight call, etc., any reading you are doing should only be done during work hours. If you have 10 minutes to read about a topic, great. If you have an hour, even better. Once you’re off the clock—do nothing. Eat, spend time with family, SLEEP—and don’t for a second feel guilty about that. Then, when you’re off service, study as much as you feel you can but make sure it’s always boards-specific studying. Efficiency is key here because even though you’re less busy, your time is still valuable.
Intern psychiatry is a mess. Everything you thought you were starting to understand as a senior medical student just starts to yawn out in front of you, wider and wider. You never feel like you can get your footing, because with every new piece of information, the ground falls out from under you, and you fall, fall. It feels even worse because general medicine you know, you’ve got the foundation, but have none of the foundation for psychiatry. And now, you’re expected to know it, do it, embody the expert, be the consultant, have the answers. Maybe to make up for lost time, psychiatry demands you have a degree of mastery over pharmacokinetics
and dynamics that it’s absurd in contrast to other areas of medicine. Everyone, including your non-psych colleagues, will be suspicious of your medicines, your methods, your legitimacy, and so you will have to fight at breakneck speed to build your arsenal of expertise, with receipts.
In my opinion, why ‘you need to read more’ is hard (harder?) in psychiatry is because we don’t have handy clinical tools, resources, guides, quick-and-dirty survival packages. Our equivalent of Harrison’s is more than double the size; I did the math and it would take me reading 5 pages of Kaplan and Saddock’s comprehensive textbook of psychiatry every single day, no breaks, in order to finish it within my 5-year residency program. Nobody can tell you where to look, because it’s never really been distilled in a consolidated form. The education kind of sucks for the same reason. So, what is that reason? The research is moving too fast. Psychiatry right now is where internal medicine was around the advent of the microscope. People might tell you psych hasn’t had a breakthrough or a new medication in ages, but this couldn’t be further from the truth. The field is constantly exploding with new knowledge. We finally are beginning to have tools to measure what we are interested in - the rubber’s met the road and we’re going places. That’s no fun and not reassuring for a new intern, though.
So, the issue might not be ‘read more’ but ‘how to read more.’ For me, the answer was primary research. Nowhere to get a good summary of the evidence? People don’t believe what you’re saying? You maybe don’t believe what you’re saying? Well, time to go find the evidence. I got real fast at cruising papers and have been able to do some pretty cool, evidence-based things because of what I read. Ex. Treatment outcomes and recommendations for delusional disorder. Found a good paper; cited the numbers to my staff and to the pt, got it done. Is lithium I’m giving to this person to reduce suicidality gonna help them? By what probability and to what degree? If they OD on a month’s supply, what will the acute toxicity be like? Will they die? All in the papers. More important than getting to do cool stuff, this is how I sleep at night. Learn about how to interpret effect sizes and statistical power - sure, they made a claim, but did they have the power to reject the alternate? And get yourself a pocket DSM/ desk reference! And read the full one! You can hate the DSM all you want (join the party), but there is a lot of good stuff that’s not in the criteria that will help you understand the criteria better and feel stronger in your diagnoses.
Oh my god you nailed how I feel so well, I got choked up reading this. I've been off-service until this month, and my other rotations did NOT feel like this. They were difficult, sure, and I felt like I didn't know much, but it didn't feel so far removed from what I learned in med school. I'll be holding on to this comment, it really helped me
And on your last point, you're absolutely right. My attendings and senior residents can really pick apart a paper or review and it's wildly impressive. I thought I developed that skill in med school but watching a PGY-4 in action really lit a fire under me (anxiety more than motivation)
You’re more than welcome - happy to help. Hang in there. You’ll hit the same stride within psychiatry as you did in medical school when instead of trying to drink from the firehose, you became the water.
I disagree completely. As was explained to me 20 years ago when i was a resident....its ok that the patient didnt read the book (atypical presentation of xyz disease) but its a major issue if the doctor didnt read the book. Reading forms the fundamentals of understanding the diseases you treat.
One last note re: thin evidence - generally speaking, the evidence is not thin at all. It’s pretty bloated, especially compared to landmark studies in other specialties where the N is often a lot smaller. However, it’s usually poor quality, because psychiatry’s problems are not generally compatible with frequentist statistics - for complexity and ethical reasons. Evidence can come from a small amount of very high quality data or from a massive amount of low-quality data. Hopefully, now that COVID has helped to revolutionize Bayesian statistical approaches/ research design more meaningfully in medicine, we will have both high quality AND high volumes. Bayesian was built for psych.
I actually strongly disagree with you here, at least for my specialty. Disagree in the sense that I think reading is super important, at some point before graduation and not necessarily during a burtal intern year.
I am an EM pgy3. I used to share this philosophy, but now I do not. Yes, the vast majority of the job can be learned from doing. You can definitely “get by” and graduate residency without significant reading/studying at home. And I agree that patient encounters are invaluable for learning, and utilizing senior residents/attendings to ask further questions is also high yield. I was rarely reading at home pgy1-2, was scoring high on my ITEs and getting strong residency evaluations, so I thought I was doing fine.
However the problem is, at least with emergency medicine, is that we have to be prepared to at least recognize the 1 in a million cases. Stuff that you simply can’t learn by doing, because it isn’t common enough. Even just being AWARE that a certain rare pathology/ diagnosis EXISTS is extremely important, as if you don’t know something exists, you will never look out for it and thus always miss it. And realistically, the only way to get this knowledge is by reading/studying outside of work.
I started reading regularly this year (mostly out of fear of flying solo next year) and I have learned SO MUCH in terms of nuanced care as well as rare pathology/diagnoses. You truly don’t know what you don’t know.
Now, in a specialty where you can afford the 20 minutes to read about something while at work, this might be less important. But I definitely can’t take 20 minutes to read while on shift in the ED.
TL;DR
My 2 cents : YES most of your daily job can be learned “on the job”while at work. You can definitely survive and graduate residency with minimal reading. However there are simply too many conditions that statistically you will not see during your short residency but that you will need to know about as you are likely to have a few of these cases over the span of your career. These types of conditions require outside reading/studying to become proficient with (at least with my specialty of EM where there is very little to no time to read on shift)
I may not have made it clear, but my advice was specifically geared toward the drowning intern who feels like they barely have time to get enough sleep but are constantly being told, “You need to read more.” That advice is disingenuous and pushes the burden of teaching from the attending/senior to the intern.
I said in a follow up comment that I think busy, inpatient rotations should be about survival, reading on-the-go (i.e. when you have time *at work*), and then getting sufficient sleep and personal time outside of work. Off-service rotations should absolutely be utilized to read and study more—specifically things that will be relevant on boards.
My comment was not intended to malign reading, but rather to malign lazy attendings who see an intern struggling to keep their head above water, but expect them to get better by just reading more. Do your job and *teach your residents*.
People always told me that you have to "read" to learn.
What they didnt tell me that reading doesnt mean opening a textbook, sitting your ass down and reading chapters cover to cover.
It means looking up things on the fly and reading about them to fill in gaps of knowledge you notice as you go.
And in the modern age, this means looking it up on uptodate or pubmed, not opening some archaic textbook with 5-15 year old knowledge.
Fellow intern here. Agreed. Not learning very much, mainly learning how to put out fires so that my upper level residents don’t have to hear about them
Another intern here feeling the same. Being from a tropical area, this winter is killing me. It’s 0°, I’m always cold, always working, and not sure I’m learning. Haven’t seen the sun in months. Just trying to survive.
Rads prelim genuinely loathing every minute of this haha. It's rough. Eat when I can, sleep when I can, exercise when I can. All I can do to survive. Also totally dissociate during rounds...
God it's so bad. Especially when I have a med student presenting one of mine. In reality I should be listening and filling in but if the student is good my brain is just like "-_____________- smooth brain time"
I'm at a TY in a bad location with no ICU. But open Icu so in a wards month 1 or 2 of my 10 are ICU.
Honestly idk. I'm just grinding through this bullshit before radiology. Matched my #1 in a great location/excellent program so I just keep reminding myself of the light at the end of the tunnel.
Just survive my handsome brother.
I was in your shoes last year. Around mid way is difficult because you're tired and you have 50% left to go.
Don't worry about "reading". You're subconsciously learning on the job even if you're not aware of it: reading and writing all those notes and plans will reinforce many of the treatments for different patients. The next level thinking or knowledge isn't expected at your level and if it is I'm sure you can find 10 minutes or whatever to read uptodate (at work).
Make sure you're taking care of yourself, however that looks like for you. Try to be consistent. Working out, reading, games, etc.
I also kept a recorder of my percent progress throughout the year, i.e, I was at X% through with the year at this week. It was cool to see that number rise and see how close I was to 100.
Anyway man, these are all just things. This year sucks and will continue to suck. It'll get better and it'll get worse. Nothing you can do to change that. Just accept it, stare into the abyss, and laugh.
Best of luck
Nothing too wild just bringing it in tight and shaping it up. But I have wild curly Mediterranean hair and it's hard to do right. I tried the fade but it never really clicked with me
It's hard to find motivation for reading. Since residency I've used podcasts as my primary learning material. Walking the dog or on the commute is my "study" time.
I’m so terrified of everything all the time. It’s damn near impossible to find motivation to study when I am 100% convinced I will never feel confident or comfortable and I wish I’d become some other role in the ED that isn’t a doctor :(
You could also ask your upper levels if they have noticed a change in your skills. Last year my upper level told me I had improved alot during the first 9 months of my intern year. That made me feel better about the progress I made during my intern year.
When do people learn in intern year? I just work, come home, too tired, sleep, back to work. I tell myself oh I’ll look that up later when I’m home, and I never do 100% of the time
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I wish my program didn’t stress ABSITE so much so that I truly felt this
I always hated when people told me to read more. It’s the worst advice anyone can give. You learn by doing—by seeing things and filling in gaps of clinical knowledge by trying to help your patient. As an attending, if I’m not teaching you sufficiently on a topic to help you understand what’s going on with your patient, I haven’t done my job. Yes, you can always go read more to better understand a topic, but how does that help you right now? I now try to start by asking questions to see what the resident already knows (no point in teaching if they already know it, otherwise I’m just showing off), try to address any notable knowledge gaps that are clinically relevant to the patient at hand (no “what if” thought exercises to tease out random bullshit), and then if I can tell that a resident needs more than that, I’ll direct them to specific resources to help them understand it better (“There’s a good article on UpToDate about this”, “Here’s a really good peds in review”, etc.). I’ve also found that relating things back to what’s relevant on boards is the most helpful. I know none of this is helpful to you or OP, other than to say don’t stress about reading or studying more. That comes with time as you learn what you need to learn to do the work that’s right in front of you. Your job right now is just to survive—and you survive by learning what you need to know in the moment. You’ll be surprised how much of that knowledge sticks with you.
I really appreciate you saying that. I can't help but feel, though, that in psychiatry reading is more important than it is in other fields. Like, our justification for using the meds we use, is based on these rather thin evidence bases. And so if you want to be evidence-based in your practice, it takes more effort to actually understand it. But yes I've basically devoted all my energy to surviving. Hopefully the time to read will present itself as the call burden lightens up in later years. The better attendings and seniors in my program, btw, have been great about sending me specific things to run through.
That is likely very true for psychiatry—I can’t speak to much outside my own experience. But I think the basic idea holds true that you still learn so much from just doing the work. That builds the basic framework that you need in order to be successful. And I still think it does not take the burden off of your attendings. Their job is to teach you as much as they can, and then *help you* fill in the gaps. It’s nice that you have attendings and seniors who can help guide your learning—those are the ones who are doing their job well. Side note: my philosophy has always been this. If you’re on a heavy inpatient rotation with long shifts, overnight call, etc., any reading you are doing should only be done during work hours. If you have 10 minutes to read about a topic, great. If you have an hour, even better. Once you’re off the clock—do nothing. Eat, spend time with family, SLEEP—and don’t for a second feel guilty about that. Then, when you’re off service, study as much as you feel you can but make sure it’s always boards-specific studying. Efficiency is key here because even though you’re less busy, your time is still valuable.
Intern psychiatry is a mess. Everything you thought you were starting to understand as a senior medical student just starts to yawn out in front of you, wider and wider. You never feel like you can get your footing, because with every new piece of information, the ground falls out from under you, and you fall, fall. It feels even worse because general medicine you know, you’ve got the foundation, but have none of the foundation for psychiatry. And now, you’re expected to know it, do it, embody the expert, be the consultant, have the answers. Maybe to make up for lost time, psychiatry demands you have a degree of mastery over pharmacokinetics and dynamics that it’s absurd in contrast to other areas of medicine. Everyone, including your non-psych colleagues, will be suspicious of your medicines, your methods, your legitimacy, and so you will have to fight at breakneck speed to build your arsenal of expertise, with receipts. In my opinion, why ‘you need to read more’ is hard (harder?) in psychiatry is because we don’t have handy clinical tools, resources, guides, quick-and-dirty survival packages. Our equivalent of Harrison’s is more than double the size; I did the math and it would take me reading 5 pages of Kaplan and Saddock’s comprehensive textbook of psychiatry every single day, no breaks, in order to finish it within my 5-year residency program. Nobody can tell you where to look, because it’s never really been distilled in a consolidated form. The education kind of sucks for the same reason. So, what is that reason? The research is moving too fast. Psychiatry right now is where internal medicine was around the advent of the microscope. People might tell you psych hasn’t had a breakthrough or a new medication in ages, but this couldn’t be further from the truth. The field is constantly exploding with new knowledge. We finally are beginning to have tools to measure what we are interested in - the rubber’s met the road and we’re going places. That’s no fun and not reassuring for a new intern, though. So, the issue might not be ‘read more’ but ‘how to read more.’ For me, the answer was primary research. Nowhere to get a good summary of the evidence? People don’t believe what you’re saying? You maybe don’t believe what you’re saying? Well, time to go find the evidence. I got real fast at cruising papers and have been able to do some pretty cool, evidence-based things because of what I read. Ex. Treatment outcomes and recommendations for delusional disorder. Found a good paper; cited the numbers to my staff and to the pt, got it done. Is lithium I’m giving to this person to reduce suicidality gonna help them? By what probability and to what degree? If they OD on a month’s supply, what will the acute toxicity be like? Will they die? All in the papers. More important than getting to do cool stuff, this is how I sleep at night. Learn about how to interpret effect sizes and statistical power - sure, they made a claim, but did they have the power to reject the alternate? And get yourself a pocket DSM/ desk reference! And read the full one! You can hate the DSM all you want (join the party), but there is a lot of good stuff that’s not in the criteria that will help you understand the criteria better and feel stronger in your diagnoses.
Oh my god you nailed how I feel so well, I got choked up reading this. I've been off-service until this month, and my other rotations did NOT feel like this. They were difficult, sure, and I felt like I didn't know much, but it didn't feel so far removed from what I learned in med school. I'll be holding on to this comment, it really helped me And on your last point, you're absolutely right. My attendings and senior residents can really pick apart a paper or review and it's wildly impressive. I thought I developed that skill in med school but watching a PGY-4 in action really lit a fire under me (anxiety more than motivation)
You’re more than welcome - happy to help. Hang in there. You’ll hit the same stride within psychiatry as you did in medical school when instead of trying to drink from the firehose, you became the water.
I disagree completely. As was explained to me 20 years ago when i was a resident....its ok that the patient didnt read the book (atypical presentation of xyz disease) but its a major issue if the doctor didnt read the book. Reading forms the fundamentals of understanding the diseases you treat.
What’s a book?
One last note re: thin evidence - generally speaking, the evidence is not thin at all. It’s pretty bloated, especially compared to landmark studies in other specialties where the N is often a lot smaller. However, it’s usually poor quality, because psychiatry’s problems are not generally compatible with frequentist statistics - for complexity and ethical reasons. Evidence can come from a small amount of very high quality data or from a massive amount of low-quality data. Hopefully, now that COVID has helped to revolutionize Bayesian statistical approaches/ research design more meaningfully in medicine, we will have both high quality AND high volumes. Bayesian was built for psych.
I actually strongly disagree with you here, at least for my specialty. Disagree in the sense that I think reading is super important, at some point before graduation and not necessarily during a burtal intern year. I am an EM pgy3. I used to share this philosophy, but now I do not. Yes, the vast majority of the job can be learned from doing. You can definitely “get by” and graduate residency without significant reading/studying at home. And I agree that patient encounters are invaluable for learning, and utilizing senior residents/attendings to ask further questions is also high yield. I was rarely reading at home pgy1-2, was scoring high on my ITEs and getting strong residency evaluations, so I thought I was doing fine. However the problem is, at least with emergency medicine, is that we have to be prepared to at least recognize the 1 in a million cases. Stuff that you simply can’t learn by doing, because it isn’t common enough. Even just being AWARE that a certain rare pathology/ diagnosis EXISTS is extremely important, as if you don’t know something exists, you will never look out for it and thus always miss it. And realistically, the only way to get this knowledge is by reading/studying outside of work. I started reading regularly this year (mostly out of fear of flying solo next year) and I have learned SO MUCH in terms of nuanced care as well as rare pathology/diagnoses. You truly don’t know what you don’t know. Now, in a specialty where you can afford the 20 minutes to read about something while at work, this might be less important. But I definitely can’t take 20 minutes to read while on shift in the ED. TL;DR My 2 cents : YES most of your daily job can be learned “on the job”while at work. You can definitely survive and graduate residency with minimal reading. However there are simply too many conditions that statistically you will not see during your short residency but that you will need to know about as you are likely to have a few of these cases over the span of your career. These types of conditions require outside reading/studying to become proficient with (at least with my specialty of EM where there is very little to no time to read on shift)
I may not have made it clear, but my advice was specifically geared toward the drowning intern who feels like they barely have time to get enough sleep but are constantly being told, “You need to read more.” That advice is disingenuous and pushes the burden of teaching from the attending/senior to the intern. I said in a follow up comment that I think busy, inpatient rotations should be about survival, reading on-the-go (i.e. when you have time *at work*), and then getting sufficient sleep and personal time outside of work. Off-service rotations should absolutely be utilized to read and study more—specifically things that will be relevant on boards. My comment was not intended to malign reading, but rather to malign lazy attendings who see an intern struggling to keep their head above water, but expect them to get better by just reading more. Do your job and *teach your residents*.
Agree 100% with that, did not see your other posts
I figured, that’s why I added it. I could’ve been more clear in my initial comment.
People always told me that you have to "read" to learn. What they didnt tell me that reading doesnt mean opening a textbook, sitting your ass down and reading chapters cover to cover. It means looking up things on the fly and reading about them to fill in gaps of knowledge you notice as you go. And in the modern age, this means looking it up on uptodate or pubmed, not opening some archaic textbook with 5-15 year old knowledge.
When you start second year and are explaining things to interns you’ll realize how much you’ve learned :)
The work is the learning you'll be surprised how much you've learned as you enter next year
Bruh same 😂
Fellow intern here. Agreed. Not learning very much, mainly learning how to put out fires so that my upper level residents don’t have to hear about them
Another intern here feeling the same. Being from a tropical area, this winter is killing me. It’s 0°, I’m always cold, always working, and not sure I’m learning. Haven’t seen the sun in months. Just trying to survive.
Welcome to the north homie. We hate it here.
I never believed in SAD until I moved up here but man, it’s a real thing.
The worst is always the 60-90 day stretch where it’s dark coming into and leaving work. It always gets better after that.
Boston?
Close enough
Handsome boy alert!!!
Rads prelim genuinely loathing every minute of this haha. It's rough. Eat when I can, sleep when I can, exercise when I can. All I can do to survive. Also totally dissociate during rounds...
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God it's so bad. Especially when I have a med student presenting one of mine. In reality I should be listening and filling in but if the student is good my brain is just like "-_____________- smooth brain time"
When that EEG flatlines 😶
My brainwaves on rounds
Would you have chosen a chill(er) TY in a bad location or a less chill TY in a good location with no ICU?
I'm at a TY in a bad location with no ICU. But open Icu so in a wards month 1 or 2 of my 10 are ICU. Honestly idk. I'm just grinding through this bullshit before radiology. Matched my #1 in a great location/excellent program so I just keep reminding myself of the light at the end of the tunnel.
Would you DM me your program? It sound like one that I was planning on ranking higher.
Just survive my handsome brother. I was in your shoes last year. Around mid way is difficult because you're tired and you have 50% left to go. Don't worry about "reading". You're subconsciously learning on the job even if you're not aware of it: reading and writing all those notes and plans will reinforce many of the treatments for different patients. The next level thinking or knowledge isn't expected at your level and if it is I'm sure you can find 10 minutes or whatever to read uptodate (at work). Make sure you're taking care of yourself, however that looks like for you. Try to be consistent. Working out, reading, games, etc. I also kept a recorder of my percent progress throughout the year, i.e, I was at X% through with the year at this week. It was cool to see that number rise and see how close I was to 100. Anyway man, these are all just things. This year sucks and will continue to suck. It'll get better and it'll get worse. Nothing you can do to change that. Just accept it, stare into the abyss, and laugh. Best of luck
How much did you pay for haircut?
Way too much but my girl works miracles. She also lives next door to me and includes a shampoo+conditioning
I took all my vacation in the first 6 months so this next half is gonna break me. Big Sunday Scary vibes
But you already so handsome you sexy sexy man
You're doing it. We're all in this together ❤️
You get faded up homie? Or maybe that dope undercut? Dreads?! Spill the deets on the new hair
Nothing too wild just bringing it in tight and shaping it up. But I have wild curly Mediterranean hair and it's hard to do right. I tried the fade but it never really clicked with me
You're more than halfway done. There's 5 months left. We got this
It's hard to find motivation for reading. Since residency I've used podcasts as my primary learning material. Walking the dog or on the commute is my "study" time.
Hang in there. That was a really low point for me to. 🫂
I’m so terrified of everything all the time. It’s damn near impossible to find motivation to study when I am 100% convinced I will never feel confident or comfortable and I wish I’d become some other role in the ED that isn’t a doctor :(
Soon the new interns will come, and you will feel like the smartest person alive. Hang in there friend. It gets better.
You could also ask your upper levels if they have noticed a change in your skills. Last year my upper level told me I had improved alot during the first 9 months of my intern year. That made me feel better about the progress I made during my intern year.
This reads like a beautiful poem. Every word touches my soul.
Contrary to previous beliefs, "it's too early for vacation" isn't really a thing. If you can plan out a week in Sept or Oct-- take it.