Paddling Upstream

by Tory Toles, MD

Residency is hard.

Family medicine residency is really hard.

Learning all the skills necessary to take care of a broad range of patients, whether it be infant or grandparent, to needing the skills to cover emergency departments, ICUs and labor and delivery decks, can be quite daunting at times. Luckily, there are plenty of resources available. As an intern, I felt like I was drowning in this sea of knowledge but gradually identified a tried and true set of resources that provided me with a life vest for my ongoing upstream paddle. So, for all you interns out there feeling overwhelmed, you are not alone! There are so many things out there to help you! The internet! Your program! Apps and apps galore!

My favorite resources to review key topics, facilitate on-the-fly learning and hit home those basics are:

AAFP monthly journals
Each issue covers three major topics pertinent to clinic and hospital rotations. The articles are concise, easy to read, up to date and evidence based. You can get them mailed to you and/or emailed through the AAFP website. When I have down-time on lighter rotations, I will read a few and even reference them for specific topic review (I have collected over a year’s worth now. My bookshelf is nerdy.)

DynaMed
This overlooked cousin to UpToDate is easier and faster to skim (in my opinion). The information is delivered in bullet-point format and is more concise and more updated (reviewed and updated weekly). If you are looking for more detailed information, then you only need to scroll down. It keeps things short at the top and then expands on topics below.

UpToDate
Of course. Best part is that it is linked to Lexicomp so you can type in topic or drug and get a good set of results. I find UpToDate not specific enough for quick review though and can get wordy so is hard to skim in a pinch.

Epocrates
It is very helpful for pharmacology like Lexicomp but easier to look up pharmacokinetic info on the application and faster to search side effects, interactions, etc. But as far as dosing for specific conditions, Lexicomp is still my go-to. All the pharmacists use Lexicomp so you can rest assured what you look up on Lexicomp will earn you rounds points and be accurate.

MDCalc
Let’s be honest, we cannot possibly remember formulas and calculators for everything. This application is gold. Sometimes if I cannot remember if there is a calculator for a specific condition, I will just type random related words in and always find something helpful for patient care. Great for inpatient, outpatient rotations and clinic.

Doximity App
In the new world of virtual visits, having an easy VV backup on your phone and phone dialer is crucial. I find the app helpful for the dialer component. You can set it to show the clinic phone number when you call patients, so you don’t have to worry about patients getting your personal number when you are answering patient messages. The dialer also has an option for video chat which can help if your virtual visit experiences glitches and you need a quick backup. Patients get a text message with a link they click, and no download needed on their end.

USPSTF and Shots Applications
Helpful for clinic well child checks and other healthcare related questions.

Program-directed didactics
These occur weekly at the program I am in and offer lectures on topics relevant to family medicine specifically. They are well rounded and cover aspects of patient care the applications do not. Even if you cannot attend, the lectures are provided to all and can be read at another date.

First Aid, Step Up to Medicine Books, Board prep books
Yes, that’s right. I still reference my old medical school books at times (call me a hoarder or masochist). The information in them becomes a lot more relevant as you go through residency and sticks in a different way when reading it again.

Library resources provided through institution
You can look up literally anything via the library.

This is a lot of information. Seems familiar doesn’t it? I found that what worked best for me was reading my AAFP monthly journals, taking notes of helpful information during didactics and using DynaMed/UpToDate (easier access on computers sometimes) /Epocrates if needed while on inpatient rotations, or if I had a quick question I needed to research on the fly. It is easier to retain information if it is tied to a patient encounter so make the most of your shifts. This also allows for less studying during your free time so you can unwind and have fun. All in all, good luck, you got this.

Winter, the dying season.

I heard a colleague refer to the winter months as the dying season and yes, as a resident covering the inpatient service at a local hospital during late November and December, that name seemed to encompass my time on the service well. It was overwhelming in its accuracy.

Performing clinical rotations in a small, rural town in Pennsylvania during medical school has made me no stranger to this terminology. But as a resident, with more responsibility, this phrase meant more to me than ever before.

On service, one ICU patient after another was dying. How could this be happening? What was I doing wrong? I felt sad, incompetent and beaten from my job. I was not sure how to cope.

I found myself recovering well during the workday, or so I thought, because I was required to maintain focus for the care of my other patients. But when my day off came around, I was suddenly and harshly thrust back into those events the minute I had the chance to relax. I was haunted by the faces of the patients I had lost and the voices of their distraught family members. I remember hearing one phone call I had with a patient’s daughter over and over any time I fell asleep, her distinct cries piercing and distinct even in a dream. Her cries brought back the faces of so many others- others from residency and others from medical school.

How do we cope with death as residents? We are overworked, over-stressed, and constantly doubting our decisions, choices, and expertise. We have limited time to process patient deaths and, I admit, in the moment my thoughts kept circling back to: this is my fault. I missed something. I made a mistake. This is because of me. Me. ME.

But this was never the case. The guilt creeps in so easily because we take this job to help patients, make them feel better and improve quality of life, relieve their fears, their family’s fears—make everything okay. But this is not always possible. Death is inevitable.

My experiences in medical school dealing with patient death ultimately drove me to pursue a career in family medicine so I could provide preventive care to reduce comorbidities for patients and hopefully, untimely deaths. They also helped me develop skills that made me more comfortable having end of life discussions with patient families while in residency. Despite all of this, the feelings of guilt and self-doubt surrounding patient death persisted.

This alludes to the importance of support and education surrounding managing patient death provided by residency programs and medical schools to address those unavoidable feelings and reduce burnout. Many articles also exist on how to deal with death and dying in medicine and how preparing students in medical school can help in the long term because this topic is so difficult for many. Ultimately, articles cannot prepare us for the emotional complexity associated with these events, but they do open up a dialogue that is also important on processing emotions. Ultimately, the experiences themselves prepare you.  

Below are some methods I have experienced in medical school and residency that have been effective for my own experiences:

  1. Support group: open dialogue about managing emotions, wellness strategies
  2. Debriefing after events: what happened, how it happened, what can be learned
  3. Co-resident reach out

It wasn’t until this winter inpatient rotation, during my intern year in residency, that I realized what I was doing wrong. I was not focusing on the exceptional care I was able to provide thanks to a wonderful team. Nor did I focus on the connections I was able to make with patients and their families. I kept making every situation about myself—but in healthcare, we work as a team. We work together to provide the best care we can to patients and I never utilized the team support that was available to me to help me process these events. Thankfully, I am lucky to be in a program where I get to work with my friends every day and it took support from my fellow residents, family and time during days off to reflect and face what I was feeling. It also took a thank you card from a patient’s family, to remind me that even if death can’t be avoided, there are still ways to help patients and their families.


Tory Toles, MD, is from Las Vegas, Nevada, and chose the University of Utah because it is an institution known for innovation and provides a diversity of educational opportunities, community involvement and strong commitment to care, all while located in an area with amazing natural beauty and outdoor recreation. Her medical areas of interest include medical education, office-based procedures, and reproductive and women’s health.. When not working, Dr. Toles enjoys indoor rock climbing, kayaking, hiking, cooking, and playing music.


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