A Day in the Life

A Day in the Life of an Internal Medicine PGY1

5:35 am: Time to start the day! I’m on-call today. First stop is coffee. I have a coffee maker at home, but I’ve been treating myself to Starbucks vanilla iced coffee most mornings as I drive to work. I only live 8 minutes away, so I chug it by the time I reach the hospital parking lot.

6:00 am: They scan my head for fever and ask me if I have any symptoms. My temperature is usually below-normal because I’m so cold from my walk to the parking lot (and the iced coffee).

6:05 am: I quickly put on my white coat and make sure my multi-colored pen is in my pocket. I print my team list for the day and clean my computer station to use for the day. I ask my night team colleagues if anything happened overnight. It turns out that one of my patients ended up going to the ICU overnight for increased breathing requirements.

6:15 am: I sit down at the computer and review my patients’ charts, checking for any updates overnight or from consultants. I jot down their morning labs, and for those who don’t have them, I give the nurse a quick, appreciative call to request lab draw as soon as they can. This is the time to replace some low potassium. Sometimes, if I have patients I know can be discharged today, I send the case manager a quick message to ask of any disposition updates.

6:45 am: I grab my face shield, stethoscope, and N-95 and head downstairs, power-walking to all the different floors my patients are located on to see how they’re doing this morning.

7:30 am: I sit down and scan a few patient charts for more information. There’s a patient who may have gout so I ask the lab if I can take a look at the synovial fluid under a microscope (no crystals, phew!)

7:45 am: If I have a quick minute, I sneak away to the cafeteria and quickly scarf down a mini bowl of Cheerios and a bottle of water.

8 – 9 am: We attend Morning Report, where a resident presents an interesting case and lesson from their current service. It’s a rite of passage that interns will be picked on during morning report. I’m less nervous nowadays and appreciate the learning. However, please don’t call on me to read those EKGs just yet!

9:30 am- 12 pm: Rounds.

12 – 7 pm: I grab a quick lunch and iced tea from the cafeteria and make my way back to the resident lounge. There are some families to call and consultants to ask about medication adjustments and pending procedures. We receive some new admissions. Some time in between, we receive sign-out from the other teams. Sometimes, our patients have serious issues to attend to during this time, like hypoxia or a low blood pressure, so we run up to the floor to stabilize them. I’m still a little lost navigating the floor units by number but plenty of nice staff direct me the correct way.

7 pm: Code Blue called overhead. I find the patient surrounded by nurses, doctors, and respiratory therapist with my senior resident running the code. I get in line to do chest compressions. I observe the sequence of events: chest compressions, pulse check, Epi, etc, trying to retain it all in hopes that I can be that senior resident someday. I spend two minutes doing chest compressions, which feels like ten minutes with my weak arms. Patient eventually achieves ROSC! I consider working out in the near future.

8 – 8:15 pm: Time to sign out to the night float team. I make sure all my sign-out communications are updated, progress notes, H&Ps are done for the day. It’s been a crazy day!

8:30 pm: I’m home - time to shower and eat a lot. I do 10 UWorld questions and message my co-interns in our UWorld group chat, since we’re trying to keep each other accountable right now. Sometimes I fall asleep on my recliner watching Netflix. Time to snooze! Nothing feels better than a good night’s rest after a long call day.

A Day in the Life of an Internal Medicine PGY2

6 am: My alarm goes off at 6am, I give it the good 5-minute snooze to let myself orient before fully waking up and getting out of bed. When on Medicine months our day officially begins at 7 am, however as with most things in medicine, work for us does not really fall into a set 9-5 type of schedule and showing up early for work 30-60 minutes is far more common. The location of the hospital is perfect for a suburban setting with lots of housing available nearby and I elected to live within a 5-minute walk so that I could enjoy the most sleep as possible. I wake up and do the morning ritual before walking out the door by 6:30am.

6:35 am: I walk into the main lobby of the med pavilion building; have a pleasant exchange of greetings with the safety checkpoint personnel and head up to stairs to the medicine resident lounge. Walking in there are typically 2-3 residents from the night team passed out on the chairs scattered throughout the room and I greet them with a good morning and turn the lights on. Today I am on call, which is a rotating coverage throughout the week typically falling on every 4th day. I identify the resident that covered for my teaching team overnight and receive handoff from them about overnight events and any follow-ups that need to be addressed. In the handoff, I take over the team phone with addition of the code phone today due to me being on call.

7 - 8 am: At 7 am my official call coverage begins and from this point until 8 pm, I am responsible for all code strokes, code blues, and rapid responses that are called overhead. This is a lingering thought in the back of my mind all day, as you never know if you will be in the rest room or cafeteria when one of these happens. However, until any of that occurs, I carry out my normal medicine duties as usual. I login to the EMR and open my team’s patient list. We currently have 11 patients from the previous day and we can receive up to 6 new patients today. With the exception of post call and 24hr call days, this is the normal average daily admission census I can expect. My team consists of myself the “senior” resident and 2 intern residents. Typically, the new patients will be split 3 to each intern. With their maximum patient load being 10 patients individually. As I review the EMR and discuss with my team about goals for the patients this morning there is a rapid response called at 7:40 am. Luckily, we have a midlevel provider team that will respond to these first and notify us if care needs to be elevated to the resident physicians. A few minutes pass by and I do not receive a call so it seems to have been something minor that I will not be needed for. I have just enough time to grab a coffee and banana before heading to the conference room for morning report.

8 – 9 am: Since we are still in medical education as residents, we have daily didactics and educational goals to meet until we graduate. Monday, Tuesday, Wednesday we have morning reports from 8-9 am when an interesting teaching case is discussed in a group forum setting with some educational points. Thursday afternoons we have didactic lectures from noon-3pm from different specialties across the medical field. Often Fridays do not have educational events however, the odd lecture may be added if an attending requests. Today we have a case presented to us about multiple sclerosis and discuss its presentation and management, with a few interjections from the associate program director about key teaching points the morning progresses smoothly.

9 am – Noon: After morning report ends we are able to start doing some bedside patient care. Typically, the attending physician will meet us about 9:30 am for rounds. This gives us a good 30 minutes to update our team lists and round out any morning test results that may have been slow to result. Depending on the day we may start in the emergency department with any patients from the prior day that are still boarded for admission but haven’t received a room yet. We then work our way from the bottom floor of the hospital to the top floor of the hospital and walk from room to room discussing each patient and the clinical course. The attending will ask questions and focus on important points to look for when treating certain pathologies.
Part way through rounds I hear overhead the dreaded “EMERGENCY CODE BLUE, ROOM 3112”, I politely excuse myself from rounds and make my way to the code. When I arrive at any emergent overhead call the first thing I do is identify the nurse and get handoff while I evaluate the patient. However, in a code blue often times there is mess of things going on and you will arrive to 10 people in the room and chest compressions already started. My job is to place roles for the staff present and coordinate care and place orders. I clear the room of staff that does not need to be present and hope that we are able to help this patient and have a positive outcome. As time passes, we achieve ROSC, the patient is transported to the intensive care unit, and handoff is given to the resident taking over care. I phone my intern to find out where they are and return to rounds. Hopefully finishing without any more distractions.

Noon – 4:30 pm: After rounds we part ways with our attending for the day and begin working on everything we must accomplish for our patients today. Things like contacting consults, coordinating rehabilitation placement with the case managers, discussing living situation with social workers, working on discharge orders, or even just completing our daily documentation charting. We are still open for 6 patient admissions and because we are call we typically will not receive them until after the regular shift teaching teams receive their patients. We can expect a bolus around 3 pm onwards which is the last time the other teams can accept admissions for the day. Today we made it until 3:30 pm before I receive the page of 2 new patient admissions. I give 1 patient to each intern and allow them time to get a brief chart review before we head down to interview the patient and perform our physical exams. I do not like spending too long in the EMR before seeing a patient due to several confounding charting issues you may find in other provider notes. It is always a good idea to just review vital signs, med list, recent labs, and brief ED course before walking in the room so I have some direction during the interview. We will complete the interviews and place admission orders and head back to the lounge to receive sign-out from the other teaching teams.

4:30 pm – 6 pm: For teams not on call 4:30 pm is the official time we can sign-out of work if all of our patient duties are met. Sitting down at the tables in our resident lounge we split up the teams that need to be covered overnight in a buddy system. Teams A & C usually get paired and covered together as well as Teams B & D. Each intern will carry the respective covering phone with both teams forwarded to it. The teams will then give a detailed handoff of their patients which will include their code status and things to watch for, somethings that may need to be followed up on, or even specific directions if specific predictable events were to happen. We will spend a good amount of time between now and sign-out tonight handling issues for these teams or coordinating urgent care if needed for our buddy teams. During this time we will also receive our additional 4 admissions and cover any other codes that may occur.

6 pm – 8:30 pm: Once 6 pm rolls around, we are officially unable to accept new patients. At this point I will contact our attending physician by phone and staff the new admits from the day if they have not already been discussed at some other point in the day. This process can take between 15 minutes to an hour depending on severity of the patient’s clinical conditions. During this time frame of 6-8pm I start to see a lot more bedside evaluation requests from the nursing staff for patients with delirium or agitation. Again, we still cover codes and rapids until sign out at 8 pm and hopefully can wrap up any of our days’ work by that point if no other distractions arise. The night team arrives about 7:50pm and we allow them to settle in for the evening before starting sign-out at 8 pm and warn them about the patients that need close attention or issues that may arise overnight. Now the day is over, and I get to head home to relax.

A Day in the Life of an Internal Medicine PGY3

5:45 – 6:30 am: Beep…beep…beep…another day! I’ll usually grab my phone and browse through the news headlines before finally getting out of bed. Residency can sometimes be insulating, and I’ve found that it’s nice to stay up to date with the world outside of medicine. With each year of residency, I’ve found that I take a significantly shorter amount of time to get ready in the mornings. And now, with the pandemic, my morning routine has been extra-quick. I’ll brush my teeth, shower, throw on a pair of scrubs, and get on my way to work all in about thirty minutes.

6:30 – 7 am: Pedal to the metal to dodge Hall Road traffic. As a native Californian, it took me a while to get used to all the potholes and “Michigan Left-Turns”.

7 – 8 am: Time to get to work on the floors. At HF Macomb, we are a tight-knit resident community and the resident lounge serves as the epicenter for sign outs/charting/note typing/down-time ultra-competitive-high-stakes Ping-pong matches. Once I get to the lounge in the mornings, I’ll touch base with my co-senior(s) who is on nights to see if there were any updates with my team’s patients overnight. After that, I’ll check in with my interns to see if they have any concerns on any one of their patients. If nothing comes up, I’ll print my list, pull up a seat at one of the computers, and start chart reviewing and then go see patients.

8 – 9 am: Daily morning report is a chance for each of the floor teams and residents on specialties to present an interesting case from the month and lead a discussion on the final diagnosis. Morning reports are attended by our associate program directors, Dr. Munasinghe or Dr. Weerakoon, or one of our other teaching faculty. Needless to say, they are a great learning opportunity.

9 – 9:30 am: Grab a coffee at Tony V’s and set up a plan with my interns for each of their patients before rounding with the attending.

9:30 – 12:30 pm: Rounding with the teaching attending begins. Before the pandemic, the entire team would discuss each patient outside the room using our portable computers and then go inside the room to examine the patient with the attending. However, since the pandemic, if a patient is in droplet precautions for COVID, then the attending physician will go in him or herself to limit exposure. As the senior on my team, I’ll “drive” the portable computer and put in orders as we discuss them on rounds to make things easier and more efficient for my interns.

12:30 – 1:30 pm: Lunch time! I’ll run the list with my team after rounds to make sure we’re all on the same page and then we’ll stop by the cafeteria to pick up food.

1:30 – 3 pm: This is the time to make sure everything discussed during rounds is implemented including discharges and following up on recommendations from consultants. This is also when we receive new patients, if we haven’t earlier in the day, up to 3 new for each intern depending on the call schedule for that day. Apart from reviewing orders, as a senior I try my best to help my interns with social work/case management calls and discharge planning as I know they also have their notes to work on. If there are medical students on my team I’ll try to pick a different topic each day and run through it with them or take them with me to admit new patients.

4:30 pm: If the patients are all squared away and the interns are completed with their work, we sign out to the on-call team (who stays until 8PM) at 4:30 PM.

Evening: Time to go exercise, shower, and figure out what to eat for dinner (the pandemic has definitely forced me to improve my cooking skills!). After dinner, I like to check in with my family and then spend some time reading on a topic from the day. Around 10:30, I’ll set my alarm clock for the next morning and head to bed.

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