American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Dear Intern Letters: Tips for Success for Incoming Residents

The following letters were sent to the Resident and Associate Society(RAS) inbox. With start of a new academic year, many members are transitioning into different roles—some still within the framework of residency, some out of residency entirely. Within these letters, the authors share their wisdom with their younger selves and others as they look back on their intern years through a more experienced, wiser lens. Enjoy these lovely letters that are packed with helpful tips, words of encouragement, and a bit of grit.

Dear Intern,

Welcome to the field of surgery. Congratulations! You did it—you’re a doctor now! Now that you have had a few weeks to celebrate, let me give you a glimpse of what this next year is going to be like.

There will be many early mornings—actually, all early mornings—and many late nights. There will be many days you don’t see the sun, and that tan you earned during your time off will rapidly fade. On your first day, you realize you have to learn quickly. There’s a new EHR to master, new order sets, and so many names and phone numbers to memorize because stopping to look them up every few minutes slows you down big time. Each attending has his or her own style, and what works for one doesn’t necessarily translate to the next. You’ll talk to your attendings more than you speak to your own parents most days. You will feel a new level of tired that you didn’t know was possible, and you’ll start to wonder if you might have a thyroid problem. Nope, that’s just residency wearing you out. The week flies by before you’ve had the chance to work on the morbidity and mortality report, study, or log your cases. How did that happen?! You get to know the hospital better than your own apartment, and the call room better than your own bedroom. And then there will be those days when you feel beat you down, you feel like you’re not doing anything right, and you seriously contemplate about what your life would be like if you just quit. A tear or two along the way is not abnormal. You are only human—but luckily, those days are truly few and far between.

At the same time, you’ll meet your new intern family, and many of them will quickly become your best friends and closest confidants. The older residents become you big brothers and sisters who genuinely want to see you succeed. These people care about you, and to an extent, truly love you. You realize your attendings are hard on you because they want to see you succeed. As the end of the year approaches, you look back on how much you have learned. You have mastered a thing or two inside and outside of the OR. You can confidently manage the floor, tie one-handed and two-handed knots in your sleep, and even started messing around on the laparoscopic trainers to prepare for to the more difficult cases you will face as a PGY-2. You have some legendary war stories from your nights on call. “Overwhelmed” has an entirely different meaning to you now than it did one year ago. Managing the cardiothoracic surgery floor doesn’t scare you anymore. There really isn’t a page you can’t handle. And somehow, in between it all, you manage to meet the love of your life.

All of the sudden, you’ll be walking out of the hospital on the last day of your intern year in late June. The sun is setting, and you realize you did it. Let me repeat: You. Did. It. You beat intern year in general surgical residency—a legendary feat. You are one step closer to becoming a surgeon. And before you know it, the new interns walk in the door...

Dear Doctor,

Congratulations on achieving one of the most important goals of your career. You're about to start a journey towards becoming the best version of the doctor you want to be. The emotions will be overwhelming, but overall, be courageous. Fear will invade your mind and body, but little by little, you will learn to control it for the benefit of your patients.

Take a moment, breathe, meditate and think about what your purpose in this profession is. Remember the first time a patient thanked you for your care, your first diagnosis, that moment when you were involved in an operation when all the sounds went out and you realized that you were in the place you were destined to be. Remember that day you said, “I want to be a surgeon!” Remember the long nights of study, the moments of joy, the tears, the victories and the defeats that lead you to surgical residency. Take note, because this will be the reminder that you are privileged;allow yourself to remember that you have in your hands the blessing of doing good for someone else. Let these thoughts be the voice that illuminates the path during the darkest days, because those days will come—perhaps more often than you expect. Soon you will realize that your training is a succession of moments that constantly prepares you for a bigger stage and preparation is the key to all success.

First, remember the most important rule. Despite how much you learn, despite how much you grow, you will never stop being an intern. So be the best version of yourself you can be, because soon you will be the role model and mentor for those that will come after you.

Second, surgery is a compilation of details that allows you to prepare as best you can to give your patients the best outcome. The profession is all about dissecting things to the smallest details. Those details are what makes the difference, whether you're doing an admission and taking a history, or setting up for a successful Whipple procedure as a chief resident.

By now you’ve realized your path to residency has been an iteration of hard work, dedication, good mentorship, and practice. Well guess what? You already know the formula for success, except you’re inputting new variables to the equation.

Third, find early mentorship, learn from the best, and ask for advice with feedback. Find your intern of the year and ask how he or she did things. Find a role model in your senior residents and do the same. Follow this person’s advice, emulate his or her work and try to be better.

Fourth, always do the right thing! Treat your patients like they are your own family. If you approach patients this way, no matter how difficult or long your day may have been, you will go home knowing that you did everything you could for your patient.

Fifth, know the important dates in your academic year and prepare. Milestone meetings, difficult rotations, and the ABSITE exam are all examples of important dates.

Sixth, acquire a surgical textbook of your choice, stick to it, and allow yourself one hour every day for directed reading. Buy an ABSITE question bank early in the year and dissect your FISER ABSITE book during your rotations.

Seventh, try to scrub as many cases as you can, and you will be surprised at how valuable it is to learn from watching. You're in surgical training and the skills will come with time, but the experience of dealing with different scenarios will only come from the OR.

Eighth, be a teacher, share your knowledge, and you'll be amazed at how concepts become clearer and clearer. Learning to be a teacher will also apply to your surgical skills—see one, do one, teach one. When it comes to book subjects or articles, read one, learn one, teach one.

Ninth, take care of yourself! If you're not healthy, you can't perform in top form. Eat well, respect your personal time, exercise and be conscientious of the people that surround you. Remember that your family and friends need as much time from you as you need from them.

Tenth, ENJOY THE RIDE! Surgical residency is long and demanding; it may involve extra years of research and you still have fellowship to come. Remember that few people have the opportunity to do what you do. Many fail to reach their dreams and many are still working twice as hard to have the opportunity that you have. So be humble and thankful, and have fun!

Dear Intern,

It will be a few more years before Lin-Manuel writes your favorite musical about some Founding Fathers. Even though you will be no fan of Burr’s free advice for Hamilton, you could use it now: “Talk less, smile more.”

Talk less, because you need to listen more. Listen to the nurses. They know more than you do and will teach you when to worry. Talk less and listen more to the respiratory therapists. All of them know more than you do about ventilators, and it will take you years before you actually understand respiratory failure. Talk less to the patients. Let them talk more to you. Listen, and they will tell you what is important. They will tell you what matters to them, what scares them, what hurts them. When you do talk, ask more questions, especially of the patients. Talk less, because your talking will get you labeled as everything from “pushy” to “incorrigible” to, worst of all, “yankee.” And while perhaps some boundaries need to get pushed, you will ultimately say something that you regret. You will lose sleep for the next decade wishing you could take it back.

Smile more, because no matter how hard your day has been, your patient’s day has been worse. Smile more, not because the patriarchy insists that women smile, but because it is actually a privilege to do this job. Smile more, because you are living out your dreams every day. Smile more, because you are making lifelong friends and colleagues. And, most importantly, smile, because that fourth year medical student who you haven’t met yet might be passing you in a hallway or in the cafeteria. Smile, because when you meet him, you get to start the rest of your life.

Dear Intern,

Do not worry. Stop looking around nervously. You are not the mistake in this class of outstanding individuals or the applicant that slipped in through the door. It is natural to feel anxious, but remember that your anxiety represents a combination of excitement to finally begin surgical training coupled with a healthy amount of discomfort from being in a new place. This is going to be a great year; in fact, it will be the best year that you will never do again. Here are my top ten tips for you, in no particular order. I hope these tips make this year easier and more enjoyable for you as you join the world of surgery.

Number 1: Take off your mask.

Establish a connection with your patients before an operation. Even on those hectic days when you are responsible for the preoperative preparation of multiple patients in different operating rooms, take a moment to drop your surgical mask, take off your surgical cap, introduce yourself, and smile. You may be nervous for your first few operations, but I bet that every one of your patients are anxious about undergoing their surgical procedures. Seeing the face of someone they can recognize after the procedure is critical to establishing a relationship and providing reassurance.

Number 2: Write everything down.

The volume of your daily to-dos in a 12-hour day will exceed anything you have experienced before now. But more than to-dos, write down names. Nurses, physical therapists, pharmacists, consultants, the custodial staff—you will see them and need their expertise often this year. For consultants, especially radiologists and emergency resident physicians, circle back every now and then with an intraoperative image or a confirmation of a diagnosis. Remember, too, that while residency may be five-ish years, few of these years are spent on the wards. Many more are spent in operating rooms and clinics. You are the visitor, and these members of the care-team (especially the nurses) are the veterans. 

Number 3: The Firehose Effect: Experience vs. education vs. evidence?

Learning this year will be different. You will learn “on-the-job” for the first time as a surgical trainee. Maximize these experiences by preparing for your cases. Review the critical steps of the operation with your attending or senior resident before the case and annotate those notes afterwards. Find one, and only one, surgical textbook to read throughout the year to establish the bedrock of your surgical education. Start practice questions for the ABSITE in November-ish and ask the senior residents about their best practices (for example, Behind the Knife, SCORE, or TrueLearn). You will want to read papers to supplement your education with evidence. Thankfully, the department’s journal clubs and conferences will cover these, but only if you attend.

Number 4: Learn the four-letter word that is safe for work.

H-E-L-P. Ask for help. Especially at the beginning of the year, ask as often as you can. Everyone is ready and expecting to help you succeed.

Number 5: Take on the PGY-2 mentality.

Remember when you were a sub-intern? Your goal was to function at the level of an intern, right? Now that you are the intern, observe the PGY-2s and PGY-3s. Within reason, spend your first several months watching closely how these senior residents work-up patients, hone their technical skills, and manage surgical complications. Take the best parts of what you observe and apply your own style. Spend the latter half of this year practicing at that higher level.

Number 6: “I don’t know.”

A paradoxical phrase: so hard to say, yet so meaningful and beneficial for you and your team when you say it. This is our trust fall. Admitting you do not know lets the rest of your team establish that you are an honest and conservative individual; practically, it lets your team know how specifically to advance your education. Remember that surgical knowledge is modifiable; integrity is much harder to change.

Number 7: Don’t forget the shoulders of giants.

Your internship and residency are amazing opportunities and remember all the wonderful people who helped you realize that opportunity. Integrate your new residency family with your constant community. Share your successes and failures, even if it happens over a quick phone call walking to your car or apartment. 

Number 8: Cross-train.

Just like any physical sport or performing art, surgical residency can be enhanced by breaking a physical and psychosocial sweat in other ways. Go for a walk, play pick-up sports, read fiction, perform live poetry. This tip will seem like the hardest on this list, but strive for wellness and be conscious about burnout. Try to form good habits early, integrating these passions outside of surgery to create time for you. It will be much more difficult later.

Number 9: You can’t spell mentor without “me.”

It is ok if you don’t know what you want to do after surgical training. However, part of soul searching is finding a mentor who can challenge you, serve as a sponsor, and help establish your professional network. You do not know who/what you do not know, but you can find someone who does. Show the initiative and reach out earlier rather than later.

Number 10: Pay it forward.

The reason many say it is easy to forget what it is like to be a medical student is because it is true. Medical education and surgical sub-internships have changed drastically since senior residents and fellows went through the process. You may not be an expert in the steps of an aortic valve replacement, but you are on the wards in the eyes of the many students rotating through the hospital. Help them shine—one of them may even be your intern one day… 

There is one tip that has not made this list, not because it has lesser value, but rather because it should be constant. Enjoy yourself and have fun. You will hear your attendings reminisce about the joys of training, the patients who taught them, and the lifelong friendships that were forged on the wards. I hope these tips help you during your journey. The eternal intern in me would suggest making this a to-do list for your first month of residency, but nobody likes a senior resident who micromanages. Best of luck and have a great year.


Your older, greyer, and slightly more experienced self

Dear Intern,

This is the beginning of a very gratifying career. You will always be challenged in positive ways. This is a noble profession that will bring you great satisfaction. When you are busy because of many consultations, it is because others trust your knowledge and judgment.

There will be many hours spent in the hospitals and offices. These experiences will build your clinical acumen; try to get involved in the treatment of a wide variety of medical conditions. A broad range of experience will make you feel more confident in practice.

Give yourself time for rest and reflection when you are not working. Keep a happy home environment. Your contentment depends on maintaining joy at work as well as at home.

Our patients put abundant trust in us. With great experience knowledge, skill, integrity and compassion, you will serve them well.

Dear Surgical Intern,

The things that follow are realizations you’ll have at some point this year. Some, though, may not come until later, and they may be of benefit to you now, so I’ll write them here. Best of luck, congratulations, and enjoy the ride.

  1. Believe the hype. No single year of life will likely compare to what you experience over the next twelve months with a group of similarly driven, talented, and entirely human strangers. You’ll laugh harder together than you ever expected, and lean on each other in ways that you’ve likely never relied on peers. Cherish these people and this amazing, terrifying year.
  2. Eat when you can, sleep when you can, go to the bathroom when you can, read when you can, call your family when you can, go outside when you can (even if just for a few moments), exercise when you can, and don’t hate yourself when you can’t. There will be nights and mornings that your mind and body are too overwhelmed to do anything other than eat ice cream and watch TV. That’s okay.
  3. Learn to triage. Your job this year is to differentiate sick from not sick, stable from unstable. Pages may pile up in the background, but taking care of your sickest patients at moments when they decompensate is the most important work you’ll do as an intern. Learn to be there before they crump and to call for help when you need it. There are more people than you think looking over your shoulder, but they’re only watching if they know about the patient and know what’s happening.
  4. When you’re taking care of those sick patients and the pages pile up, nurses and others may become frustrated with you.  Go to them—instead of being frustrated with one another over the phone—and use some version of these words: “I’m sorry I couldn’t get here sooner, what do we need to do right now to take care of this patient?”
  5. Make things happen. People may not tell you this, but it’s possible that you’re the single most important member of your service. When the team disassembles after running the list, it’s your job to advance patient care as quickly and safely as you can against the whirring machine that is modern, American healthcare. How quickly you can get patients up and moving with their foleys discontinued, how efficiently you can get patients through their CT scans and upper GI’s, and how thoroughly you can get them ready for discharge to rehab or home—confident in their understanding of the next steps in their care—often dictates the success of the entire team.
  6. Competence and kindness are the currencies of the realm.
  7. The stress of this year will pull down your emotional armor, armor that you may not even know that you wear. Expect it, be aware of it, be okay with it. Be responsible about what armor you put back on.
  8. Work as hard as you can for those at the margins. Learn about the programs that surround your institution for managing addiction, and about the services that are available for the homeless and those with the least resources. Lean on social work, case management, and physicians within your health system who have made this a focus of their practice.
  9. The sooner you can find the rhythm of floor, the sooner you can get to the operating room and to clinic. Your work as an attending will involve operating and choosing who to operate on—get to the places where these things are learned.
  10. If you or one of your co-residents needs help—get it. It may not feel like it, but the team will survive without you. Go to the doctor when you need to, go to the dentist when you need to, and see mental health professionals when you need to.
  11. Write it all down. The way different attendings approach different procedures, the things that come up during the day that you don’t fully understand and you’ll need to read about that night, and—most importantly—all the things and people that make you laugh and make you cry. If you don’t write it down, it will all evaporate faster than you ever imagined it could.