INTERN BOOTCAMP
Be the Most Effective Intern in Your Program
Introduction
Understand the why and how behind this series as Dustyn prepares you for success.
Introduction to the Bootcamp
Congrats! You're ready to be a resident. So what is this and how will it help you? Dr. Williams explains as you take the next step in your career.
Perfect Practice
Perfect Practice makes perfect. Dustyn shares his view on Malcolm Gladwell's 10,000 hours, the amount of time it takes to be an expert at something, and links it to residency training. The most important lesson is that if you train something the wrong way, you get really good at being bad. Practice does not make perfect. Perfect Practice makes perfect. This course is designed to give you the tools, experience, and wisdom needed to start perfect practice from the start.
PACE for Residency
Show up prepared on Day 1 of residency. No one holds your hand after orientation. Prepare for intern year by doing the OME content in your specialty again, with this specific approach to ensure you have the foundation of knowledge you'll need to thrive and grow during residency.
Time Management
Prioritize tasks with a common value: patient care. Having these lessons down will lessen your burden and make the load manageable.
Urgent and Important
Prioritize tasks with a common value: patient care. Urgent things are things other people want done. Important things are things you want done. Learn to prioritize requests and tasks, but also learn how to say "no," or "I'll get to that later" the right way.
Turkeys and Windows
More advanced prioritization is based on the time needed to get something done. More than Urgent and Important, some tasks take time to complete (turkeys), and others have specific times (windows) when they are more likely to be done faster. Maximize time management by ordering tests, consults, and procedures when no one else is early so you can do other tasks while the "Turkey Cooks."
Data Tracker
The book that manages your patients day-to-day expedites decision making, note writing, and decision making. The essential tool for tracking patients in the hospital day to day. Cultivated over Dustyn's residency, this is the final product that he used (and uses as an attending) to maximize efficiency, plan his day, identify trends, and have it all in your pocket (without a 3-minute login time every time you want to look something up).
To-Do Lists
The daily tool that makes sure everything gets done for the day and helps remind you today what you did yesterday. Forgetting to do something may be obnoxious (AM labs) or catastrophic (changing antibiotics). To-Do Lists keep sanity to your day, ensure that nothing gets missed, allow for communication between residents, and are a tool Dustyn used through residency and still uses today as an attending. Learn how to build them, use them properly, and the tips and tricks that maximize their utility.
Your Usual Day
Plan your day, and plan your rhythm, to maximize efficiency and effectiveness. Turkeys, windows, rounds, notes ... there's a lot to do in a day. Mapping out your day every day, knowing what to do at what time, and preparing yourself for interruptions will make your day move even more smoothly. There will always be emergencies, sure, but having a rhythm helps check your sanity and helps you practice perfect.
The Morning Workflow
Efficiency, Effectiveness, Day by Day. Seeing the Data Tracker and the To-Do list in action, Dustyn shows off the EMR he uses (but doesn't like). He shows you how cumbersome it can be to use an EMR. He also shows how utilizing the skills in the Time Management section may seem daunting but are actually quite effective and efficient.
H&P Miner
Training wheels. Do this one sloppy so you can make your data tracker look clean. H&P Miner is the right side of the data tracker, the day of admit. It's the training wheels. Until you learn to manage such a tight space with a pen, use this page to remind you what you're supposed to extract out of the system and the patient. Allow it to be written quickly, sloppy, and with errors. It's the rough draft, the first pass.
Once you have all that information, you can take the step again to enter it cleanly into your data tracker. Eventually, you wont need this. Dustyn just uses a folded 8.5 x 11 piece of paper and knows where things go. But as you warm up, this is a good way to keep track of an order and a check list to make sure you're getting it all down.
Clinical Reasoning
Understand the art of medicine. Medicine isn't black and white in the real world. Logic frameworks save you time and save lives.
The Art of Clinical Reasoning
How Doctors Think, How Doctors Want You To Talk. Understand how doctors think. How to present a case. How to practice medicine. No matter what field you are in, everyone thinks like this and expects you to think (and therefore speak) like this.
Treatment Thresholds
How sure do you need to be to give a treatment?
When do you give a medication? How sure do you need to be to treat something? Is it ok to treat two things at once?
Heuristics
Mental shortcuts that screw you up even while you're aware of them. Mental shortcuts. You are not in control of your own mind. It will take shortcuts. And because of that, you will make errors. Learn the difference between analytical and intuitive reasoning, see the mental calculations attendings are making without telling you (don't just emulate them), and go beyond pattern recognition to reduce clinical error.
Wards
Ok, it's time to be efficient and concise. Stand out by presenting the right information the right way.
Spoken vs. Written H&P
How to present a new patient to an attending. Written H&Ps are supposed to be thorough, complete, and contain all the information possible. They do this so that anyone after you has access to the information they need. WHEN YOU SPEAK to an attending or a group, NO ONE WANTS THAT. Here's how you actually present a case, with tips and pointers along the way
Spoken Daily Rounds
How to present a patient in the hospital on daily rounds. You have a Data Tracker, a To-Do list, you've seen the patient, and made decisions. Daily rounds should be concise, to the point, and relevant. Learn how to separate important from relevant (Spoken vs. Written H&P) and the format an attending expects you to present in. Speed up your presentations, speed up rounds, sound more intelligent, and get more out of rounds.
Presenting Old Patients as New
Know exactly what to say in each situation.
This has been the most difficult thing for Dustyn to teach residents as an attending. What he does is give different examples, playing off the iSOAP model from Spoken Daily Rounds, showing you how to expedite the presentation while still being appropriate. Know what to say, when to say it, and how to show the difference between what you think and did and what someone else thought and did.
Remediating Oral Presentations
Faculty Development for an Intern. This is material that we coach exceptional attendings how to do. When a presenter is bad at giving a presentation, "be better" isn't very useful. Most attendings won't have this skill set; they may not even be able to identify what's wrong with your presentation. This allows the learner to show introspection, to identify where their own deficiencies are, and offers solutions to improve upon their oral presentation skills.
Writing Orders
Old school beats new school. With the advent of EMR, putting in an order is really easy. But the computer now dictates care. How much lasix? Must be 20, because that's at the top. No. This teaches you how to write paper orders, prescriptions, to place orders into a paper chart. This throw-back teaches you what you never learned - WHY the orders look the way they do in the computer. Learning how to write paper orders helps you understand what you're doing, and lets you write orders when the system goes down.
Admit Orders
Old school beats new school, again. Admit order sets are great for quality measures and attendings done in training. Admit order sets are just another box to check and another way to practice poorly. Knowing how to do an admit order set will enhance your ability to admit a patient correctly. Learn what EVERYONE ELSE in the hospital needs to do their job, and learn the options you have, the requirements, and what you imply by what you write.
Calling Consults
When you need help, sound smart. Calling consults is probably something you never did. Oral communication between a doctor and another doctor will facilitate the desired outcome. But there are some things you can do to prepare for the call, some etiquette you should follow, and some must-dos to make the consult as effective as possible.
Returning Pages
Controlling yourself despite the most obnoxious, intrusive device ever created by humans. The pager is the ultimate interruption. You are busy. They are busy. You are heated. They are heated. Learn to calm down, learn the proper etiquette, and what to expect (and usually not receive) when you return a page. Screwing this up is a massive withdrawal without you even knowing it.
Shorthand
Make your life easier. Use shorthand. Learning to annotate on paper makes your life infinitely easier. Copying from and learning from an EMR system on how things should look and how they should be displayed will make your life a living hell. Learn shorthand to speed up your day, make your time management tools more effectively, and make your life a whole lot easier.
Interdisciplinary Rounds (IDR)
What YOU should expect and do during IDR. IDR is not for you. It is everything OTHER than what you trained for. It is a time to make deposits into everyone else's accounts, to make ancillary staff feel appreciated and included, to let them vent. What is IDR? And how should you handle it? What should you do? What shouldn't you do?
You
Maintain and balance stress, emotions, and residency. Understand and invest in yourself so it doesn't impact your patients or peers.
Five Stages of Death and Dying in Residency
The bad stuff you will go through that no one else will tell you about or admit that they went through it too. Residency is the hardest thing you have done to date. It will be the hardest thing you've done in your life. EVERYONE has gone through the 5 stages of death and dying. 1% will admit it. 0.01% will know how to help you. Learn what to expect at different points in your training, and know that it is ok and that there are people who can help if you ask.
Stress and Growth
Stress makes you grow. Anything else doesn't. Too little stress and you get bored. No growth. Too much stress and you panic, survival mode only. No Growth. Learn to push yourself to the limit, to bend the border of your ability and grow, but also how to spot (and then change) periods where you are not growing. At no other time will you have the supervision and ability to try, to fail, and to grow as in residency. Don't squander it.
Drive
Internal vs. External Motivation. Motivate yourself. Motivate others. Carrots and Sticks vs. Mastery, Autonomy, and Purpose. A reduced version of Dan Pink's book (and Ted Talk) "Drive" as it relates to residency.
Emotional Battery
Introspection, energy, emotional bandwidth. Your soul, mental fortitude, and ability to process society and remain polite. Codified to your cell phone, this explores and identifies what drains you, the dangers of being drained, and finding how to recharge yourself.
In Your Box
What you can change, what you can't change, and what you shouldn't bother with. Residency is hard. You will have little emotional and intellectual bandwidth after work, notes, personal care, and whatever other responsibilities you have in your life after all that. There will be things you can control (yourself), and things you can't (famine, war), and those aren't hard to spot. But be careful of the things you could influence if you invest enough energy. Leaving completely drained ... is it worth fighting at this stage in your career? Learn "what's in your box" and what's not worth dumping whatever remaining charge you had left.
Others
Improve outcomes by raising the level of the team. This can be a high-stress job. Navigating it and being a leader pays off. Here's how.
Finite and Infinite Games
Change the way you see the world, people, and become more effective. A cerebral look at your perspective on others. Establishing relationships with people becomes the key to growing your sphere of influence, or impacting change, and becoming more effective. The entire life of a medical student has emphasized "get ahead at all costs." Time to change that to "there is no grade, there is no class rank, only effectiveness." To do that, you must change the way you see people.
Emotional Bank Account
Codification of your relationship with every person in your life, including patients, staff, colleagues, and supervisors. Every relationship comes with its own emotional bank account. Learn how to make deposits, flush the accounts, and be rewarded for the efforts you make over time. Also see the potential catastrophe of withdrawals, what they are, and what happens when you overdraw.
Winning Arguments
Remaining effective for your patients and your team even if there is a disagreement. When there is an argument, both of you are wrong. Learn how to effectively manage a disagreement without draining your own emotional battery or withdrawing from the emotional bank account.
Documentation
Meticulous detail in a fraction of the time. These tips and tricks will save you hours daily.
H&P Requirements
All the elements required in an H&P to look good and bill well. Learn the elements of an H&P which may seem trivial but count a lot for a) helping future physicians who see this patient, b) applying the appropriate number of items so that your group can bill appropriately, and c) where you can take shortcuts with EMR, and where should you actually pay attention.
D/C Summary
The most hated document by residents and the most important document you'll ever write. Dustyn explores the different elements within a D/C Summary, his own personal beliefs on what makes a good one, and offers both how to do it right (communication between physicians) and how to just get it done (cheating using EMR).
Progress Notes and EMR
Copy and Paste. Autopopulate ... but do right that which you need to do right. If you are doing the work well - caring for your patient, presenting on rounds, getting feedback, Dustyn shows you how you can cheat the system to make note-writing a breeze. He also identifies some pitfalls EMR has created that worsen your documentation. What you need for billing, what you need to do for communication, and how you make your life easier doing the most hated daily task of all.
Saying it Right
Translate what you know as medical terms into the words the rest of the medical universe uses. CMS language is irrelevant to you. But CMS language is the only language the rest of the medical universe uses. Case managers, quality control, insurers, the federal government, DHHS ... literally everyone else wants CMS language. From billing and coding to mortality prediction to CDC publication of disease data, you must learn to say it right.
Clinic Notes
Efficiency, Effectiveness, and Meticulous Detail, in half a second. Dustyn shows you what he did in clinic. Autopopulate, copy and paste, prepare ahead of clinic. While EMRs are designed to help with billing and coding (this is NOT efficiency or effectiveness), Dustyn shows you how to use the EMR system to simultaneously deliver the optimal level of care while also satisfying bureaucratic requirements.
Transfer of Care Notes
When you leave, make it so like the person who picks up from you, is you. Step down notes, end-of-rotation notes. This is the time when it is the most difficult for the resident who picks up your patient to know what's going on. You've been cheating with your progress notes the entire month. Take the time to do it right. Learn the elements and the reasoning behind a transfer of care note that makes your life harder for one day but makes the life of the oncoming resident infinitely easier for weeks and makes massive deposits in their bank account.
Obvious After It's Obvious
Be professional on and off the clock. Emails, calls, manners, and more. The little things can make your life that much easier.
Emails
Effectiveness, Respect, Professionalism in writing. You've been writing emails your entire life. Now at the most professional level there is, learn what you should and should not do in emails to demonstrate professionalism and respect. But also learn how to write emails to get a response and the response you want.
Phone Calls
Patience, Respect, Professionalism in speak. You know how to answer the phone, don't you? Learn the proper etiquette for making phone calls, taking phone calls, and speaking to people you don't know.
Bureaucracy
Learn the team hierarchy and your role. Know the unwritten rules and expectations your attendings have of you.
Team Hierarchy
Learn the roles, and play your part. Learn the MD team hierarchy and learn your place. We want to create a "no-blame culture for patient safety" (we do), but there's more to it than that. You don't know what your residents are doing, and you certainly don't know what your attendings are doing. Knowing your role on the team, learning the expectations, and what you can, should, and should not do will help you fit in.
Work Hour Restrictions
What Residency Programs REALLY want to tell you about Duty Hours. 80 hours a week, huh? Ok. Learn what "Duty Hours" actually mean, why they came about, and hear all the things a program actually wants to tell you but can't.
Telemedicine
Telemedicine is rapidly expanding around the globe. The art of clinical reasoning doesn’t change just because you’re on camera, but you’ll need to know the basics of telemedicine as a medium to deliver effective care.
What Is Telemedicine?
Understand the difference between Telemedicine and Telehealth.
The Path to Clinical Reasoning In Telemedicine
Understand the path to clinical reasoning during the telemedicine encounter and effectively communicate with your patient.
Tactics and Execution of Video-Based Encounters
Effective telemedicine conferences can be tricky, but in this video, Dr. Williams coaches you through the ins and outs of a successful telemedicine visit.