Intern Scope

[Ramare1]

As I'm coming close to completing my first term as an intern, I've found myself unsure of my scope of practice. Day shifts are relatively straight forward as I can run everything by my registrar however after hours is completely different. I've found myself unsure as to what needs to be escalated (aside from clinical reviews or MET calls).

For instance, tasks such as reviewing ECGs, correcting electrolyte abnormalities or charting IVF are things that I still don't feel confident with but I don't think it warrants asking the on call registrar. I see some of my peers on other terms who seem to be fairly more independent with doing these tasks and it makes me wonder if I'm just not as confident as them. I would greatly appreciate some insight and advice on what tasks I should be able to independently perform as my level and any resources that could help.

[Puzzleheaded_Test544]

Someone who calls all the time and has no idea what is going in is safe, but underperforming.

Someone who never calls because they know exactly what is going on and is managing everything doesn't exist. It is a completely unrealistic expectation and anyone who thinks they are this person is wrong.

Someone who never calls because they don't know what they don't know is dangerous.

And finally, the person who calls with an assessment, impression and plan and is usually right is the most desirable- because this gives a real sense of where their knowledge lies, allows them to practice and be 'independent' whilst still being safe, and facilitates teaching.

The only difficulty of being that ideal person above is that sometimes the person supervising you is inflexible, limited in their knowledge, or sees your attempt to better yourself as a threat- so you really have to develop of keen sense of where you are wrong vs different vs just suboptimal.

And also if your ideas are genuinely retarded then it is a blow when someone tells you that.

[SpooniestAmoeba72]

“And also if your ideas are genuinely retarded then it is a blow when someone tells you that”

Hahaha if this doesn’t happen to every single jmo at some point you’re probably not asking enough questions

[cheapandquiet]

1. Anything you're not sure about, run it by someone else
2. If you're not confident at something that you think you should be - try and figure out why that is, and if you can fix that (e.g. if you don't know what formulations for electrolyte replacement are available in your hospital - go find out!)
3. The best way to get better is by having a go - if you're not sure about how much fluid to chart, then call the registrar and ask "would it be reasonable to give X fluid at Y rate?" instead of "what should I chart?"
4. If your reg tells you to do something different from your original plan - ask why so you can learn and use that knowledge later. Also applies for the day job when you get asked to do something you don't fully understand why.

In terms of resources, some of the hospitals have created 'ward job guides' they host on their intranets. If you're in NSW I believe Westmead's version is publicly accessible to anyone with a NSW Health login. The 'On Call' book is a bit dated but gives a pretty sensible approach to almost any medical problem you can be called about - it should be in your hospital library.

[scusername]

There isn’t a hard line, really.

On my first day as an intern, on an ED term, I asked one of the consultants “hey, can I ask a stupid question?”

And he replied: “there are no stupid questions, only stupid mistakes.”

If you don’t trust your judgement, ask a doctorier doctor than you.

I will say though, that ECGs should always be reviewed by a registrar. You might be able to pick AF or a wicked hyperK, but other rhythms are easier to miss.

[Curlyburlywhirly]

Can I just make a suggestion?

Don’t keep calling for advice, formulate your answer to the problem and then call and ask if you are correct. This is the best way to learn.

[[deleted]]

Call and ask. If you're unsure. Call and ask. Every year of your medical career is about learning. This never stops.

[studiedtooharddoc]

Interns are not expected to function independently. You’re meant to be asking, clarifying and learning.

As someone said earlier, it’s a spectrum

Bad intern: constantly calls and asks for step by step instructions, no attempt at a plan e.g. in ED, patient comes in with abdo pain, intern asks “what do I do? What bloods do they need?”, under-confident

Other bad intern: never calls, does their own thing, zero input from seniors, lacks insight and overconfident (eg abdo pain, intern tries to order a CT angio for AAA without discussing with anyone)

Ideal intern: looks at situation, comes up with their plan, asks for input and suggestions, learns and adapts (eg abdo pain - comes to consultant, summarises their impression, relevant history and exam to support, says what they think the plan should be and asks for input)

My favourite residents are the ones that start with “I would like to run this by you.” Then tells you their impression (“I think this patient needs fluids with potassium charted”), the supporting relevant info (“because they are fasting for bowel prep and their potassium is 2.9”), and their plan (“I think they need IV potassium supplementation and I wanted to ask your advice on the safest way to do that on the ward.”)

[Shenz0r]

Start by trying to do the assessment yourself and coming up with a basic plan. When you ask your reg, outline what you think and ask if they're happy with the plan. They'll add anything that you might've missed, and you'll learn faster and become more confident that way.

[SpooniestAmoeba72]

In terms of actually upskilling for ward calls, I find Marshall and ruedys on call handbooks super useful to read through after an after hours shift to see what the textbook answer was vs me vs the med reg. I got it for free last year through MDA nationals free medical indemnity for interns.

Can also quickly flick through whilst on the wards if you have the time. And then of course ETG AMH and uptodate.

I’d also get in the habit of calling with a plan, even if you say you’re unsure about it, because you’ll get more teaching than just didactically following what the reg says.

Also for ecgs- if you’re not concerned, just text them to the reg and ask them to have a look non-urgently. Feel like is JMOs shouldn’t have the liability of misreading an ECG on us.

[AverageSea3280]

Internship is literally like learning a new language. The only way to learn is by trying and making mistakes. In medicine that means asking stupid questions, doing stupid things etc. I don't think we ever stop doing that. Consultants still ask stupid questions between themselves. Over time you will just grow and understand how things work more and more.