DIP Episode 86 - The Intern That Thrives (a guide for IM and TY interns)

Okay, welcome to episode 86 of the Divine Intervention Podcasts. In today's episode, I'm going to essentially discuss how to be an excellent intern. There are many facets to being an excellent intern, but that is... This is just basically like a general overview of your job descriptions as an intern, especially for a medicine intern or a transitional year intern. I'll talk about some key things, expand on some key things, and just essentially mention some high-yield key things you should do as an intern. Really, these are born from my experiences, being an intern, from mistakes. I have made as an intern, from good things I've identified in other people doing well as interns, from mistakes I've identified, from other people that have made mistakes as interns. I'll just talk through these things in no particular order, and hopefully this should be a relatively short podcast and we'll get through this. What's your job description as an intern? First thing is to shop on time for stuff. The thing is, you always want to be early. Don't build a reputation as a person that is always late, because the thing is, you'll get noticed, and then ultimately you'll get into trouble with that. People think of it as like a professionalism issue. Professionalism, once that word becomes dungled around you as a deficiency you have, that can raise some very serious problems in residency. Because the thing is, reputation really does matter a lot in residency.

The reputation you build early on is the thing that may ultimately stick with you for the rest of residency. Believe it or not. Because the thing is, you may do so many good things in the middle of residency, but really it's the reputation that you acquire early that will ultimately stick. Remember this when you're studying an intern year. Essentially, you just work on building a strong solid reputation with your other residents, with nurses, with your attendants, with the support staff. And really, if you establish this good reputation, it will follow you through. Even if you make some mistakes along the way, after that initial good reputation that you have built up. So you should establish a rule for yourself that you try to get to things like five minutes ahead of time. Because really, if your program director notices that you are always early, you're always present at things, you'll be in your program director's good books. And this is basically like, you know, pretty much establishing a savings account that you can, we draw on. You can draw on in the future when you get into trouble for some troubles you may face down the line in residency. Second thing is to sort of work hard in everything you do, right? Again, don't be known as the lazy resident. Because again, if you acquire a reputation as a person that does not do their job, it's a very short fire way to destroy yourself in residency. So really, don't be the person that ponds of admissions or other people.

Don't point off work or other people. Because really, if you acquire that reputation, people will retaliate and you really will not like the outcome. I mean, the unfortunate situation in many hospitals and many residency programs is that hospitals are like a cesspool of gossip. So don't let bad information, bad information like, oh, this person doesn't do their job spread about you. Because again, that can put you into trouble that you do not envisage. Because once, like really, like literally it's your job. So you might as well just do your job, right? Work hard, do your job. So avoid this. Just don't be lazy. Because I mean, you know what you signed up for, even as a college student going into a med school, right? So just freaking do your job and you will not get into trouble. Because the thing is, once a rumor starts spreading that you are lazy, it is a very hard reputation to repair. And the problem is, if it gets into the ears of the wrong people, so basically like people in charge, like program directors, directors of medical education and whatnot, you can actually begin to have troubles in residency that are more far reaching than you would ever, that you could ever imagine. Okay? I guess next thing is obviously right, you want to see your patients in the morning, pre-around and around on your patients. That's kind of obvious. I will see more than that. Another thing is you want to get good at coming up with assessment and plans, right?

I mean, as a medicine intern, that is like almost like the being of your existence, right? You want to come up with assessments for problems and plans. And I mean, this may be something I may talk about in the future in a more expansive podcast, but really, how do you identify a problem, how do you make a problem list? It's actually quite easy. The way you make a problem list is one, you identify lab derangements, right? What an usually epic and external power chart or whatever you use will blunt out these things in red, right? If they are lab derangements that are like serious, they should make it to your problem list. If they are chief complaints that are serious, if the patient's chief complaint should certainly make it to your problem list, is there a test that was done like a chest x-ray or an echo or whatever that identified a problem that should make it to your problem list? Added super derange vitals like sinus tachycardia or whatever that should make it to your problem list. Added chronic problems the patient has at home that they are bringing with them to the hospital like diabetes, like heart failure, that should make it to your problem list. That is essentially your problem list. And then literally for each problem that you write down, the next thing you want to do is to say, okay, how will I assess this problem, right?

So if for example it's a pneumonia and you're like, oh, you know what, I'll assess this with a decrement in the white count with a clinical improvement in the patient symptoms, with an improvement in how the chest x-ray looks every morning. Like ask yourself, how will you assess these problems, how do you plan to fix this problem, so what are the interventions, right? Are you giving antibiotics, are you sending them to the cath lab, what's your intervention for the problem, and then how will you track the resolution of that problem? If you basically answer those questions for each of those problems you identified, you've essentially made up your plans for your problems, okay? And really if you're very systematic in this format, in setting up your assessment and plan, you will be an intern that misses very few things with regards to a patient's hospital course. And then you also want to, if there is some kind of outpatient follow-up that's needed for the patient's problem, you also want to focus on that in your assessment and plan. Don't forget to continue home medications, right? That's important, right? So you don't want a patient to be on like a chronic med at home, and then you don't do a med-rex, so you don't continue those medications in the hospital, and then the problems they came into the hospital with you add more new problems to that, that's not necessarily a prudent, right?

And then another thing with regards to discharge summaries, discharge summaries, again this is a freestyle podcast. Discharge summaries, I'll encourage you to start writing them when you admit the patient, okay? And then update them every day. If you do that, your discharge summary can take like a minute, two minutes to write. But if you don't and you wait, you're kind of like, musin-lazy and about, and you wait till the patient is living the hospital to write your discharge summary, then it can become a one or two-hour ordeal, right? Especially for patients with like prolonged stays in the hospital, like 30, 40, 50, these stays in the hospital. That can make your life a profoundly miserable, right? And then one other rule is studying one going high, this is basically a medication rule. So I will encourage you start and opti-trade as needed. It generally does not make any sense to try to go for the highest nuclear dose of a particular medication. That's not particularly smart, because if the patient has an on-well-compside effect, trust me, you probably would not want to experience that if you can avoid it. So start at a low dose, you can always opti-trade to the patient's clinical response. And then you definitely want to learn how to read EK Gs and chest X-rays. That's just an important thing you want to do as an intern. You also want to get good at presenting your patients. Again, I will encourage you to build a standardized approach. In fact, you know what?

Let me just combine this with another thing I guess I want to talk about. And that's like, noteworthy, presenting, all that stuff. The key principle here is you want to develop a standardized approach to things you do in residency. Like tasks that you repeat every day in residency, try to develop approaches to those tasks. Because the thing is when you develop an approach or like an algorithm in your mind or like a template in your mind that you use for like abstracting information from a patient, rounding in the morning, writing your HP Is, writing discharge summaries, admitting patients to the floor, admitting patients to the ICU. If you can cope with a standardized approach, one, it makes you very efficient. And two, it makes that process almost mindless. Because the thing is if you gain a reputation as an efficient intern that is also accurate, it builds a lot of goodwill with your seniors, with your attendants and with your program director. That's the kind of good attention you want to attract as an intern. And again, you can do this by developing approaches to all these things. Like literally, I mean, I'm a transitional year resident. I have approaches to how I write discharge summaries, to how I write HP Is, to how I come up with assessment and plans, to how I round on patients in the morning, to how I do my pre-around in, to how I do my presentations. I have approaches to how I do tasks that I repeat often. Right?

Because again, that makes me super, super, super, super efficient. It is one thing that has helped me tremendously as an intern. Now, next thing is, right? I mean, obviously you're going to admit patients as an intern. That's your job. And then you also want to learn how to put in the right orders. In fact, if I were you, this is one thing I would focus on very early in the intern year. Like knowing how to put in the right orders for common things. Right? So like medical-admet orders, ICU-admet orders, like SEWA protocol orders, opioid withdrawal power plants, blood transfusion orders, orders for pressures, orders, like common studying doses of narcotics, orders for the different insulents, like visual-ballast regiments, orders for ventilators, orders for the different types of aprons, orders for blood draws, orders for CB Cs, for BM Ps, for cultures, like respiratory cultures, blood cultures for consults. I will encourage you to figure out how to put in those orders, because trust me putting in orders is actually maybe one of your top three responsibilities as an intern. And if you can get very accurate at doing this, it will make your work really fast, because you don't need to keep asking, oh, how do I put in this order? How do I do this? How do I do that? So, ask your seniors early and often how they put in certain orders, so that you know exactly like literally like what you're typing to the order screen, so you know what you are ordering for specific situations.

Now, if you know that, I mean, there are even other sets that you can create, or other sets that already exist, right? So, like other sets for like HB, for example, those are things you sort of want to be able to conglomerate into, like, like, a power plan for yourself. Because think about it, right? You can save your, if you do the work once of sort of like grouping all the HB labs together, and all the HB labs together, and all the HIV labs together, you can just literally click on two things and you have all those labs ordered. Instead of, for example, having to order like the HB surface antigen, and the HB core antibody, and the HB surface antibody, and all that individually as you're putting in orders, right? These are all things that can save you time and make you super efficient as an intern. Now, your next task as an intern is to do when you're entering exams and your boards. So, you may see, divine here, you go with the whole test taken again. The thing is, many people think that studying your residency should not be a thing. Well, think again, you could not be further from the truth. Let me tell you why, and I'll give you some very good, very compelling reasons why you should study your residency. The first thing is, you want to be competent. The thing is, many people think that, oh, you get competent just from seeing patients. That is not true. You can actually learn a lot from literally studying.

Because the thing is, when attendants begin to see as a person that has a good knowledge base that is competent, guess what? You become more trusted and you become less big if such a word exists. If you want to be independent in residency, you can actually acquire a lot of independence if people know that you are competent. And trust me, competence comes from seeing patients and also from learning your craft by literally studying. Okay? The worst thing that can happen to you as an intern or as a resident is to cause patient harm because you have a lapse in your knowledge. Classic example is like screwing up a code because you don't know your A.C.A.L.S algorithms. Again, do people make mistakes, of course, you can make mistakes. But egregious mistakes, common things that pretty much everyone knows but you don't know because you are not spending time to attend to your knowledge base that can put you in trouble very quickly. You can put you into the bad book of your program director. It can also be a source of lawsuits, not just in residency, but even as an attendant in the future. And again, just remember, it's your job, right? Like literally, it's your freaking job. You might as well get good at your craft. This is something you are going to do for the rest of your life, right? I mean, if you're a transitional, you're interned going into like another specialty, that's a different story.

But regardless, this is your job, this is what you're going to do for the rest of your life. You might as well spend the time in a controlled environment to learn your craft really well. And the thing is, studying also helps you with exams, right? Because the thing is, say for example, right, you study routinely, you do well on your training exams, the thing is that will help you buy a lot of goodwill. And it actually gets unnecessary attention off your back. Let me give you an example, right? So say for example, you're doing super well on your training exams. The thing is, you may actually be able to get away with stuff that other people may get in trouble for, right? But if you sort of look at it on the flip side, if you perform poorly on your training exams, you essentially attract attention that is not the good kind. You basically put yourself on your program director's reader, because your program director begins to see you as a person that is at risk for failing exams in the future. So you essentially come on that, they are watchlight and to be honest, this is the last thing you want to do. You don't want to come under the watch light of a program director. And this is something you may see divine, come on, it's not a big deal. It's something you may not understand now, but when you get into a residency, you will understand the period of coming under a program director's watch light. It's something you will understand when you start a residency.

The thing is, when you come under a program director's watch light or you come under the watch light of where there are tendons of your seniors, little things that others may do that may not attract as much pushback will attract a lot of pushback if you're on people's watch list. It basically makes your residency experience very uncomfortable. And you will essentially be in a situation where you're like trying to go up both and beyond and trying to prove yourself, because you've just established this bad reputation as a person that is at risk for not doing well on exams, right? You essentially begin to walk on egg shells, and that residency is already stressful enough. You don't want to put yourself under this cloud. Now, next thing is you want to be humble. Okay, as a resident, don't be proud. Don't be egotistical. Don't be the person that everyone says, oh, this guy has a big ego. Be humble. Try not to stare up jealousy on your own. I mean, obviously some of this is out of your control, because some people are just jealous, but be a teachable person. Don't be the person that always boasts. Don't disclose your test scores ever. Don't be the person that says, oh, oh, you know what I scored in the 99th percentile? I'm not sure in an exam. Don't disclose your test scores ever. Don't be the source of that information. If other people hear from other people, find whatever. But do not disclose your USMLE scores. No, just your scores are for you.

Okay, they are for program directors. They are not for public knowledge. You don't need to disclose your test scores to other people. Okay, don't be the person that answers every single question and money report. Because the thing is, if you're proud, you will attract attention. And again, the attention you attract will not be the good kind. Because the thing is, medical professionals in general are very competitive people. So if they see that you're succeeding so heavily, and they're not, and you're boasting about it, the thing is, that jealousy can spur core residents to basically try against you and start doing things that can undermine you and pull you down. Okay? So again, be careful. If you're humble, you will very likely not get into these kinds of troubles. Okay? And I mean, the unfortunate thing is, sometimes you may be super humble, but some people are just super jealous by nature. Some people just do not like seeing other people succeed. And they're not succeeding. So, in view of this, be careful in residents. I'm not saying be suspicious and be like always, oh, I'm watching out. People are out to get me. No, no, no, that's not what I'm saying. You don't need to be suspicious, but be cautious. Okay? Think twice before you trust people, because people can stab you in the back. Okay? So be very careful, be very careful in residency. Okay? In every organization, not everyone is going to be your friend.

I mean, even the Bible says this, that a man's enemies and members of his household. If you look it up, I believe it's a verse in the book of Proverbs. Okay? So just be careful. Okay? Not everyone is out for. No one, not everyone is pleased with your successes. Okay? So just be careful in residency. Now, next thing is, you want to be an excellent communicator. Okay? Communication is an extremely important in residency. In fact, I will probably make a podcast that is targeted specifically towards communication as a resident. The thing is, if you're a good communicator, you can prevent many patient care errors. If you pass along the information, you know, in a clear, succinct manner. Right? Many conflicts, believe it or not, that are rising residency. Many patient care errors that are rising residency, all are rising from a failure of communication. So as an intern, try to always keep your attendance, always keep your seniors in the loop. Okay? Don't be the person that acquires a reputation as, oh, he did not hand off correctly. He did not pass along this information really well. Remember, if an dense statement, when you're doing handoffs, like, if this happens, this is what you should do. This, that's a very good means of practicing a good communication. And again, if you're an excellent communicator, you will attract attention to you, but you will attract the good kind of attention.

I mean, one thing that senior of mine thought me, that has helped me a lot, is like touching base with nurses in the morning. Right? So, for example, in the morning, after I like see a patient, and I know what I'm doing for that patient for that day, guess what I do? I walk to the nurse and say, so, for Mr. X, this is what I plan to do today. He's going for this at this time. This is what I plan to do to Diplata Blah. And I ask the nurse literally, like, at any concerns you have, devise those concerns, and we walk together to deal with those concerns. And then I ask, is there anything you need from me for this patient? If they need it from you, you fix it right there and there. The reason I do this is, it basically prevents you from getting on necessary pages during the course of the day from nurses. It's a very useful skill. In fact, I'm very thankful to my senior, that actually thought me that. Your latest responsibility as an intern is to do research. If you don't do research, you're very likely not be able to get into fellowship. And you'll just basically limit your career options if you don't have good research on your books. Next thing is don't lie. The thing is, if you lie, people will not trust what you say. If you don't trust what you say, they will essentially begin to question and recheck your every move. And trust is one thing you definitely want to build as a resident. Now, next thing is document, document, document.

This is something that you will understand the importance of when you start residency. The thing is, people cannot lie or argue against records that have been kept. If you are called for an emergency situation on the floor or something unusual happens during the course of the day, just go ahead and write a brief note, write your reasoning, write how you assess the situation, write down what you did in clear terms. Because again, it's in the medical record. If something is documented, you likely will not get into trouble. Especially if you explain a good reason why you did certain things. Document, document, document. The brief note is your friend. It is extremely, extremely, extremely important. Now, next task as an intern, right, is you want to stay under the radar, but you don't want to be seen as a person that is completely quiet. Because the thing is, if people see you as a person that just keeps withdrawing into your shell, people can begin to pick on you and you can also get into trouble that way. You certainly do not want to do that. You want to fly under the radar, but you want to be a person. Remember, medicine is a team sport. You want to fly under the radar, but you also want to run interference with your core residents.

You want to be, basically, you want to put yourself out enough to be like, oh, people know you, but you don't want to put yourself out too much to where people think you are ego-tistical, but you also don't want to put yourself back too much to where people think you're weirdo, and you're not a team player. Because again, that can begin to bring up issues for you in residency. Now, next thing you want to do in residency as an intern is to a mass political capital. Basically, this is like gaining goodwill. There are many ways you can gain goodwill, and I'll say probably the easiest way to gain goodwill is to respect your nurses. The thing is, if you do simple things like gradient nurses, touching base with your nurses in the morning, responding to your pages in a timely fashion, coming when a nurse like pages you or calls you and says that they are concerned about a patient and they want you to come and assess the patient, go and assess the patient. The thing is, if you do these little things here, and then really, to be honest with you, these things are not hard. They are very easy. If you do these things, you will build goodwill very, very, very, very quickly. And the thing is, this goodwill will essentially spread around the hospital like wildfire, and you'll make it possible for you to get things done for your patients quickly.

And the thing is, nurses will be willing to go to bat for you, other residents will be willing to go to bat for you because they know that you've established goodwill. So basically, the way you've established goodwill is by doing good deeds that you never know where you would need. Let me just put it this way, because I mean, I'm a Christian and I don't do good deeds with the expectation of a return. But remember, the Bible says that you reap what you sow, right? If you sow good deeds, you reap goodwill in return, okay? So just sort of keep those things at the back of your mind, okay? Again, please, please, please, don't build a bad reputation with nurses. You will make your residency experience miserable if the nurses hate you, okay? And at the end of the day, again, remember, these people you're working with, you're all your colleagues, your one big family, okay? So act appropriately. And also, it's probably a good practice to collect phone numbers. You'd be surprised at how quickly you could get things done if you have like the phone number of like the urology chief resident or the anesthesia resident or whatever. If you need to get across to people quickly and efficiently, if you have their numbers, that's a very good quick way to do that. So I'll encourage you, collect phone numbers, save them, you never know where we'll come in handy in the future.

Especially like numbers of like nurse practitioners and physician assistants that work with like the different medicine sub-specialties that can make your life super, super, super, super easy. Because those people are usually the gateway to their, to their respective sub-specialties. Another thing you want to do, make your attendance life easier, make your seniors life easier. I mean, they're basic things, right, that you can do well as an intern like Scott work. You can do Scott work very well. I mean, you've been a medical student for years, right? You can do Scott work really well. Make your seniors life easy, make your attendance life easy, and again, these are just all means of acquiring a good will. Although don't try to be so independent that you are then handling dangerous situations on your own without putting your attendin and your senior in the loop. That can get you into trouble really quickly. So if you need help literally, ask for help. And again, avoid professionalism issues. Professionalism is probably something I should essentially make a podcast on in the future. It's just one of those terms that if it's dangled along with your name that you have professionalism issues, that is something that is very hard to repair in a residency. I'll just put it that way. And again, try to avoid programs with your program direct, I mean, problems with your program director. Just try not to get in the bad books. The program director can make your life profoundly miserable.

Really, your goal every single day is to just get into your good books. And again, I've talked about many things you can do that can help you get in your program director's good books. It's not like your program director sets out to make your life miserable. No. For the most part, on the most circumstances, program director is actually working your best interests. So make your job easier by just doing the right thing. If you do the right thing, you'll be in your good books. If you do the wrong thing, you'll be in the bad books. So don't be in the bad books. Because at the end of the day, they can make decisions that can have telling consequences for your future as a resident. Now, when you start a new rotation, meet your senior media attendants and set expectations early. Ask them what are your expectations of interns or whatever under these circumstances. Like what are specific things you love people to do. And then every week, ask for feedback. Do you think a meeting expectations? This is essentially like a nice way to almost control the narrative you're getting evaluations at the end of a rotation. Yeah, I really want to try to keep this thing to 30 minutes or less. I'm going to sort of speed up here a little. Another important thing is sort of set up social needs of your patients early. So classic things you'll probably see if you work at any big hospital is like getting patients placed for like endocratitis.

Like after they clear the blood infection and then they need like IV antibiotics for a long while. If a patient has osteo and they need to get to a facility to get like IV antibiotics or a person needs to go to rehab after their hospital state. These are things you want to sort out early, right. Just one of those things you want to lit like in fact, I'll tell you this. When you're at meeting a patient as part of your workup of a patient, ask yourself, are there any social needs that may impact this patient's state? If you identify social needs literally once you're done with the admission, go meet social work and begin to see these things up from the get go. It can make you very efficient and it can actually reduce a patient's length of state in the hospital. Remember, pre-serts, getting placed, all that stuff insurance approvals take time. So stay then early. So that while you are taking care of the medical problems of a patient, you're also taking care of the social problems of a patient. So that as the medical problems are resolving, the social problems have already been resolved and they can get out of the hospital as quickly and efficiently as possible. Now, also you want to get good at some basic procedures like intubation, placing material lines, placing central lines. If you're really going home, maybe getting good at placing gambros, those are things you use for temporary dialysis. Those are things you, especially intubations, right.

You want to get good at intubations. It's one thing that may save your butter, especially if you have a crushing patient in the future. And this last rule is something I've read a lot on SDN and is a useful rule to know. Remembering that they can always hurt you more. They can always hurt you more, right. So what does this mean? Basically, if something happens, don't be the person that always complains, right. If something is not egregious, if something is something you can tolerate and just deal with and doesn't affect your life significantly to be honest, don't complain against your seniors, don't complain against your attendance. I'm not encouraging bad behavior here, right. Again, in fact, this, basically what I'm saying now does not reflect the views of any residency program I'm associated with. But basically, I'll just tell you this, don't be the person that always complains. Okay, don't be the person that always complains. If you are master repetitions, the person that always complains, people can begin to turn against you. And whether you like it or not, as an intern, you have a lot less power than a second year and a second year has a lot less power than a senior resident and a resident has a lot less power than an attending. Okay. So again, don't be basically develop some sort of thick skin. Again, if something really bad is happening and this is like affecting a patient, affecting you personally, obviously you should report those things.

Again, I'm not saying to keep these things in, but don't be the person that, oh, you report every single thing. You just basically build a bad reputation and basically let's just say you may have certain unforeseen consequences from being the person that just does not get along and always reports everything like every little thing that happens gets on the your skin. And not acquire that reputation. So I think I've probably said enough and this is this, you know, looks like a pretty good a stopping point for me. If you have any questions, feel free to reach out. I'll try to make more residency focus podcast in the future. And again, as I round up, I want to mention that I offer one on one tutoring for the USM. I'll start with step one, step two CK, step two CS and step three exams. I have tutor thousands of people that have done super well on these exams. Talk about like 98, 95th percentile sort of scores. I also tutor for the pre clinical, medical exams, the third year shelf exams, the internal medicine, training exam and the internal medicine board exams believe it or not. And I also have admissions committee experience with a top three medical school have been on an admissions committee before. So I actually prepare like era's applications for med students applying to residency and I'm just applications for college students applying to med school. Like I can do more interviews, I can help with personal statements and all that stuff. Okay.

And on the off hand, you have a friend or a relative that needs tutoring or organic chemistry. I also offer tutoring for those for organic chemistry as a discipline. So I hope you have a wonderful day. I think this is probably like a record for me. This is like the third podcast I believe I'm making today. Today is obviously a day off. So I'm trying to like make the most of my free day and by turning out as many podcasts as possible. So have a wonderful week ahead. I wish you the very best and God bless. And the match is actually coming up this week. So I'm wishing everyone I hope you all match. If you don't match, remember it's not the end of the world. There's the sub, there's a scramble. It's an anxiety provoking process, but you know, pray. Okay, I'm a Christian. I believe in prayer. Pray. Okay. Sick good advice. And you know, just try to play your cards right and learn from your mistakes. And you know, I wish you all the very best. If you're ever in any like ten or situation, you can reach out and I can try to draw from my wealth of experience. Just try to guide me in the right direction. So have a wonderful week. God bless. I'll see you in the next podcast. Thank you.

Professionalism, specifically avoiding any perceived deficiency like lateness or laziness.

By identifying lab derangements, serious chief complaints, abnormal test results (e.g., CXR), and chronic home problems.

Start low and titrate up based on clinical response, rather than aiming for the highest dose immediately.

To prevent a massive, time-consuming ordeal at the end of a long hospital stay; updating them daily keeps the process quick.

Developing standardized approaches or templates for common tasks (e.g., writing HP Is, rounding, admitting patients).

Research; lack of research limits fellowship options.

Lab derangements, serious chief complaints, abnormal test results (imaging/labs), and chronic home problems.

Nurses; simple acts like greeting them or responding promptly to pages build significant trust.

Becoming incompetent, which can lead to patient harm and damage professional reputation/trust.

Update the summary every day upon admission to prevent a massive backlog later.

Never disclose them; they are for program directors only and can attract unnecessary attention/jealousy.

They act as gateways to sub-specialties and allow for quick, efficient communication when needed.

Lab derangements, serious chief complaints, abnormal test results (imaging/labs), and chronic home problems.

Nurses; simple acts like greeting them or responding promptly to pages build significant trust.

Becoming incompetent, which can lead to patient harm and damage professional reputation/trust.

Update the summary every day upon admission to prevent a massive backlog later.

Never disclose them; they are for program directors only and can attract unnecessary attention/jealousy.

They act as gateways to sub-specialties and allow for quick, efficient communication when needed.