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

Dear Intern Letters

Authors Share Tips for Success with Incoming Residents

The following letters were sent to the RAS E-News email box in the month of June. The month of July starts a new academic year, and 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...

Thank you!

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