The time has finally come, after years of study and placement, you’re going to clip that swipe card to your hip and start as an intern. You’ve probably had a lot of advice, from supervisors at placement, talks at university, or articles about how to succeed in internship: be organised, write a list of tasks to do, ABCDE etc.  This advice, along with everything you’ve learnt throughout medical school has prepared you for your first year as a doctor.

However, starting as an intern is a little more nuanced than that. You’re a newcomer to the hospital and there’s a lot that comes with that. You’ve had some experience as a student, however your main job to this point has been to learn and absorb information. Now, you’re a part of the mesh that is our hospital system, you have a vital role to play in upholding the balance between continuing to learn, putting all you’ve learnt into practice and adapting to the idiosyncrasies of this unique workplace. There’s a lot more to this job than just clinical reviews for hypotension and charting paracetamol.

Through this article, I hope I can offer some insight into some of the challenges that may arise, that I have found often go without mention, and especially as someone new to the hospital system, can be difficult to navigate.

At first no one knows what they're doing

After some initial nerves, some familiar and new faces in orientation week, it’ll be time to start work. At some point during your first few days something will come up that will stump you. It could be your registrar asking you to order a CT (on a system you’ve never used before), or a ward nurse asking you, after hours, if it’s okay to give the metoprolol to the patient with a heart rate of 63.

Internship is a constant barrage of self-doubt, second-guessing, and eventually realising everyone just figures it out as they go. In time, you’ll be ordering CT’s without a second thought, and giving the CT registrar your patients eGFR without skipping a beat.

When I asked my surgical registrar how he dealt with having to learn so much new information, he responded, “soon enough you realise everyone is just figuring it out as they go, then one day you’re standing at the end of the bed spilling out an assessment and plan based on things you’ve picked up along the way, it just happens.”

Feeling like you know less than when you started medical school is fine. It’s normal. You’ve probably heard it before and it certainly has held true for me,you’ll learn  more in your first year as a doctor than you feel like you did in all of medical school.

Asking for help is the best thing you can do

On my first day on the wards, the team senior resident asked me to go and put a cannula in one of our patients. “That’s fine. That’s something I can do,” I thought. I was wrong. After multiple attempts, even more apologies to the patient, I reported to the nurse that, “no the cannula’s not in yet”. I went and sat in an empty office thinking, now what.

Sitting around in the resident’s room conversation turned, as it often does, to career planning. Everyone seemed to have some elaborate and calculated plan, and of course I was asked, “so, what do you want to do?” During medical school I’d thought somewhat about this question, but since starting internship I’d been more and more unsure. I gave my standard, “I’m still figuring it out, but probably not psych,” response, but it sat with me. I had a mini-early-career-crisis over the next few days, and found myself sitting in that same office thinking, now what.

Internship is full of being stuck in situations that you don’t know how you got in, and even more situations you don’t know how to get out of. For the most part, the best thing to do is ask for help. Many people you work with have been through most of the things you’re going through, and usually they’re happy to either help you through them, or give you some advice to workshop them yourself.

For me, the first-day intern, asking for help with a cannula felt like a momentously stupid request. What I didn’t realise was that most of my seniors had been in this exact same situation and were more than happy to help. I’d really been stressing out for no good reason.

This extends to things like career planning. Throughout the beginning of internship I’d felt as though I was lacking direction. We had been allocated mentors in the hospital I am working at, so I turned to him for some advice. As an experienced clinician and all round good person, he gave me some reassuring words that I don’t think are circulated enough in the competitive and pressured environment of being a junior doctor, “it’s okay to focus on being good enough, and trust that it will come with time.”

The hospital can be a social minefield

Traditionally, when anthropologists want to learn about a new culture they will go and live amongst a community, immersing themselves to learn the intricate social rules and hierarchy that govern how people act. This is exactly what it can feel like once you start spending 40 hours a week (sometimes many more) in the hospital.

The politics of working in a hospital can have implications for a lot of what you will do, and as a junior, it’s easy to get caught up. You will often find yourself at the mercy of a policy or procedure manual you don’t quite understand the reasoning for. More commonly, you might get stuck trying to figure out who exactly is meant to be doing what. When a patient thought he had swallowed a toothpick in ED, I subsequently had to consult the ENT, who suggested it might be a more appropriate query for gastroenterology. Gastroenterology then proposed it might be more appropriate for the acute surgical team, who kindly informed me this consult would be a more suitable case for the colorectal surgery team. After a series of dials and 2 hours of my time, the advice was to tell the patient to go home and come back if they had any pain.

As you start to work you begin to realise that everyone knows everyone. “Oh yeah, he was a year below me at uni,” or “I worked with her in woop woop for a term, she’s really thorough.” You start building this persona for yourself as soon as you step into the hospital. What you quickly realise is that although people do make mistakes, and everyone inevitably misses things, that if you have a good attitude and work ethic, you’ll start to develop a good name for yourself. 

Be thorough to the best of your abilities, and document clearly, after all your notes have your name stuck to them for the remainder of eternity. The best, and I believe most important advice I’ve been given is to be a kind and respectful team player. Trust people when they say, being rude to nursing staff will come back to bite you.

You’re going to see things you don’t agree with

From consultants taking off masks during the peak of the Covid-19 pandemic, to heavily abridged versions of consenting people for surgery, to complex treatment plans being glossed over with patients on the morning ward round, you’re going to see practices that you don’t agree with.

For some of these matters, there are important reporting channels that need to be followed that will vary from institution to institution. For a lot of them, however, you realistically may not be able to do much about them, there, at that moment, because of your position.

What you need to remember is that as a junior doctor, you are in a position where you can be a great patient advocate. You’ll be able to go back after the ward round and explain the changes in medication, you’ll be able to make sure when Mr. Jones goes home, he fully understands what the consultant meant when she said, “wean the dex by 10 a day for a week then 10 on alternate days for 3 days, then stop, no questions? Good.”

Each time you are in a situation where you feel slightly uncomfortable is a good time to reflect. A lot of the time these situations arise as a result of an overworked and/or under-slept senior who is just going through the motions. Use these examples and think about how you’d try and do differently, when you’re in their shoes.

Communication is key

Learning to communicate effectively in the clinical environment is akin to learning a foreign language. But no matter who you’re talking to, communicating effectively will make your life a lot, a lot, easier.

It is always good to know exactly what you want out of an interaction with someone else. From this, you can try to figure out what relevant information you need to communicate to the person you’re talking to. If you’re asking the cardiology registrar for a consult on your patient with chest pain, their family history is probably pretty important. If you’re asking the orthopaedic registrar for a review about a fractured little finger for the same patient, you can probably leave out that part about their dad’s cholesterol.

If you’ve had a blabbering mess of a conversation and after 10 minutes of conversation (4 and a half of which you blanked out for), you feel like you still have no idea what the outcome is, trying to summarise at the end, is a great way to make sure you’re on the same page. Simply asking “okay so just to confirm, we’re going to go with…” has saved me a lot of silly mistakes.

How you communicate will also change a lot with who you’re talking to. When you call up a nurse to check up on a patient, it might be better to refer to the patient by their bed number. If you’re talking to your consultant later about the same patient, they might only know them as ‘Ms Smith, the lady with aspiration pneumonia day 5 post-BKA.” Picking up on these patterns takes a bit of time, but if you try to take note and use them purposefully, you’ll be speaking the hospital’s language in no time.

You need to take care of yourself and those around you

Internship is tough. There’s definitely blood. On hot days, there is sweat. At some point, for you, or someone around you, there’s going to be tears. One thing you will be told a lot is that it's tough. You have a lot of pressure on you, and at times you have to deal with some confronting situations. You and your colleagues around you are only people, and this can be hard to remember sometimes.

When speaking to a friend from medical school about internship so far, they told me about walking into the lunchroom one day and finding another intern there, eating their lunch. After chatting for a few minutes he simply asked, “and how are you going?” This was enough for her to breakdown in tears, she’d had a rough week and was feeling pretty overwhelmed. They were able to sit down and talk, and get help through the JMO Support Line (1300 JMO 321 - only currently in NSW). It’s always a good idea to ask those around you, and yourself, “how are you going?” 

The transition from medical school to internship is the first major career transition you must make as a doctor, and it’s probably the biggest. It’s easy to get overwhelmed, stressed out and begin to fray a bit at the edges.

It’s also one of the best experiences I have had, and I don’t think this is emphasised enough. You’re going to make new friends, learn a whole bunch of new things, and hopefully even help change some people’s lives.

Try to focus on doing your job as a JMO as well as possible, when times get tough, take it one day at a time. Find out what support systems are available where you’re working, and stay in touch with friends. Clip that name tag to you clothes and good luck!

DRS4DRS promotes the health and wellbeing of doctors and medical students across Australia and can be accessed here www.drs4drs.com.au, or you can access Dr4Drs at: 1300 374 377 (1300 Dr4Drs).