Let me just ask my senior resident… Oh wait, that’s me now…
Recently I have been thinking a lot about what makes a good senior resident. I learned very quickly early in second year of residency that being a good intern does NOT mean that you will be a good senior. When you’re an intern, you get very efficient at taking care of your small collection of patients—you know them in and out, you call consults like a pro, you multitask effectively, writing notes while simultaneously updating the list and putting in your orders. You can write H&Ps fairly quickly and know exactly what your patient needs to get discharged. As an intern, you become great at getting your work done for your patients and getting home on time to preserve whatever small social life your work life allows for.
But being a senior is a whole different ball game. Now you are managing the entire team of patients AND your entire team of interns. Now it is no longer your primary responsibility to see patients, write their notes, check in with the nurses, get all the orders in, update your list, and sign out your patients to the next time. While it is your responsibility to make sure all of that gets done in a timely and safe manner, it is also your job to teach your interns how to do this independently and efficiently on their own. It is also your primary goal to make sure that everything gets done for every single patient on your team, and to double check everything that is being done by your juniors while not hounding them and not doing things for them. At the end of the day, when something does not get done or was missed it is your fault as the senior resident for not noticing this. Seniors are also responsible for thinking about discharge goals for each patient, and how to move them in that direction; sometimes interns can get so caught up in their primary tasks that it is up to you to ask the question, how can I get this patient home? Do they still need IV fluids, can I change them to oral antibiotics, do we need to repeat labs or a chest XR to make sure their persistent fever isn’t a worsening infection?
In some ways being a senior is a very freeing experience—now you get to take a step back and actually think. Think about why your patient is here, why are they not improving, what are you going to do overnight if your respiratory kid decompensates? It is also your chance to learn. Learn about the evidence behind using IM epinephrine vs. Terbutaline vs. Magnesium in status asthmaticus, or look up what Lennox Gastaut Syndrome actually entails and why your patient is a classic example of it. Being a senior means you get to clean up the sign out list, and learn what is important and what is not, to really dissect your patient’s labs and TPN and make sure you are optimizing their medications and treatments in the best way possible. Because you have freed your responsibilities of day-to-day tasks it opens up an arena to truly learn medicine and figure out how you want to practice as an attending. What antibiotic do you like to use for lymphadenitis? How conservative or liberal do you want to be with a patient who is here with fevers on antibiotics but has a documented viral infection? What kind of a leader will you be in a rapid response or code situation? And the eventual goal is that by example, or actual face to face teaching, you can impart this knowledge to your interns so they too are prepared when they are eventually seniors.
It is also very interesting to be in a situation where you know all the hidden secrets of the way the hospital works, that even the attending doesn’t know. Which medications require a prior authorization? How do you order blood STAT in the ED? What are all the back door numbers to MRI after hours? These are the secrets the senior learns, and teaches the intern, and the attending doesn’t even know exists.
But the unfortunate reality is that senioring is not that easy. You don’t go to sleep as an intern and wake up the next morning as a senior with this automatic ‘zen learning mindset’ where you forgo all of your previous responsibilities and all of a sudden all you care about is learning and thinking, and knowing hidden secrets. No, first you need to tackle your main responsibility which is making your interns the best they can be and teaching them how to complete their own tasks.
And that is so much easier said than done.
We have all had the senior who is nervous, neurotic, micromanaging—you know, the type that says “Okay, we need to consult ID for this patient… did you consult ID yet??” Um, how was I supposed to do that in the two seconds gap between you telling me to do it, and asking me if I did it? Or the senior who greets you with, “hey, we have two admissions already in the ED and we need to finish sign out quick because the nurses are changing shifts and they are going to start paging you soon, plus Mr. Jones wants to see you because he wasn’t here for rounds and is mad that nothing is getting done,” all before you can even take your jacket off! These are the ones who interrupt you during sign out, even though you were just about to say what they said.
Then we have the seniors who have the sink or swim mentality. The ones who get sign out in the morning, and go straight to Au Bon Pain to get their breakfast and enjoy their coffee; they don’t change the board so if you forgot to put up your pager then your poor comrade from overnight will continue to be paged; no orders are put in during rounds because it is your patient and your responsibility to do so. These are the seniors you are nervous to text overnight because you don’t want to wake them up and feel stupid for asking them a question, or inconvenience their sleep.
And don’t forget about the super nice senior. The one who does everything for you—you go to order a CBC and see if was already done by your ninja senior during rounds. Or you go to cancel someone’s NPO and IVF, only to have the nurse call you that your senior already did it. Sure it’s super nice and helpful, but at some point it’s irritating that you don’t even get to do your job. And are you really being set up for success if your senior is doing everything for you? What are you learning then?
So how do you find the perfect balance in-between? The basic progression I have seen is that second year seniors (those who are brand new) are still very nervous about loosening the reigns and having all this responsibility, that they usually embody the neurotic micro-managing senior. Slowly as you progress into third year, you learn what real emergencies are, which kids are actually sick, and what is worth fighting over, and slowly move towards the laid-back supportive but not in-your-face senior. The one who is there to support you and teach you, but not do everything for you.
This month I have been primary senior on the subspecialties team in my hospital. It is the team with all the patients admitted to any specialty service—Pulmonary, Cardiology, Nephrology, GI, Neuro, Endocrine, etc. So it goes without being said that the team has multiple different attendings and fellows, none of which are in-house 24/7, and can get extremely disorganized very quickly. And this is also at a time when the intern class is being expected to transition from being interns, to being early-seniors; ie, they are expected to present cases are Morning Report, they are expected to discharge patients independently, they are to call the shots and come up with the patient’s plan on their own, be adept at ordering things and calling consults, etc.
But the same way we do not go from intern to senior overnight, so the interns do not make this transition overnight either. And I am left figuring out how to be supportive and make sure that everything gets done, while also letting them be independent and take ownership of their patients.
How do you balance giving interns independence, while also making sure everything gets done, especially when it gets so busy and chaotic? Sometimes I find myself doing the job of the intern and the senior because it’s just easier for me to get things done. But then everyone suffers—the interns do not learn, and the senior responsibilities take even longer to get done since your senior is too busy being an intern! How are the interns going to learn all the hidden secrets, or how to senior, if you never give them the chance to learn? But at the same time, when things are busy and the interns are struggling I don’t want them to feel abandoned or that I don’t care. After all, seniors are not above patient care.
I don’t know the answer to all these questions. I want to think that as I have progressed through residency I’ve gotten better at being there in the background but not doing everything for everyone. But like everyone, I have good days and bad days. And the team has busy days and slow days. And every team has a range of skill in both interns and seniors.
Being a senior is hard work. Being a successful senior sometimes feels like an act of magic. And I hope that someday soon I too can master that book of spells and find the perfect balance.
