April 14th, 2021

Top 21 Thoughts for ’21

Sneha Shah, MD

Dr. Shah is a Chief Resident in Internal Medicine at the University of Colorado.

What I Wish I’d Known

Here is my advice for medical students, interns, and senior residents. These are things I wish someone had told me. I write from the perspective of an outgoing Internal Medicine Chief. Many thanks to my co-chiefs for their input and their support throughout this year.

Medical Students

  1. Be honest about your career interest. If you’re a through-and-through surgeon on an internal medicine rotation, tell us you’re going into surgery. Your team can then find ways to engage you in medicine from a surgical lens. We know not everyone will choose internal medicine.
  2. Avoid discounting your skills by saying “I’m just a medical student.” We all were medical students once. If you’re genuinely trying (and not hurting patients), no one will fault you for being completely wrong.
  3. If you are actively listening to your team, you’ll never have to ask, “what else can I do to help?” Figure out what your senior needs, and do it. If it’s unclear, a secret way to ask would be, “what’s left on your checklist that I can take over?”
  4. Don’t answer questions directed at other learners. Don’t interrupt presentations. If you’re asked a difficult question, say, “I don’t know, but let me look into it, and I can present it later.” Then, do that!
  5. Be in charge of the patient room! Write down team names and updates on the dry-erase board, return the tray-table and TV and blankets to their previous positions, ask whether the patient wants the door open or closed. These are little things, but we will notice you doing them. They matter more than you think.
  6. I know everyone tells you this, but PUT YOUR NICKEL DOWN! Giving us three treatment options and choosing the wrong one is MUCH better than giving us three treatment options and stopping! For brownie points, tell us your clinical reasoning when choosing that treatment (wrong or right), and we’ll be very impressed.
  7. You want your evaluations to read, “he/she worked at the level of an intern.” Figure out what this means within your team, and strive for it.


  1. If someone offers you the chance to go home early, take it! It’s not a trick.
  2. Keep a log of all the patients you see (last name, first name, and date of birth will do the trick for all EMRs). If that’s too much, at least keep track of all the patients you saw whose cases kept you up at night.
  3. If your expectation is to work hard, reality will certainly be easier. Those who expect a 40 hour/week residency all the time are the unhappiest.
  4. When picking up overnight admissions: read the H&P last. If you review the chart and come to the same conclusion as your colleague, chances are… you’re both right.
  5. Write less when pre-rounding. Try your best to present mostly from memory. As this gets easier to do, you’ll know your clinical reasoning skills are improving. It is possible!
  6. You’ve never seen HHS, and you never will. Order the DKA protocol.
  7. For prelims: Don’t be known as the “XYZ-prelim.” Be known as the person we want to convince to stay in internal medicine.

Senior Residents

  1. The calmer you are, the more your interdisciplinary colleagues will listen. Take a deep breath, don’t show your inner panic.
  2. Start thinking about the patient’s disposition location and outpatient medication reconciliation from day 1.
  3. No talking behind the backs of your intern or medical student. No talking down about other specialties in front of your learners. If you need to vent, do it with a trusted peer or chief.
  4. If you can afford it, buy your interns and students lunch one Sunday.
  5. Most conflict arises from poorly set expectations. So set the tone for your team by setting expectations. If you can joke around within your team, work will become fun.
  6. If you’re frustrated by a system or situation, have a strategy to prevent that from affecting the care you’re providing to the patient in front of you.
  7. Take responsibility. Be there for your patients and colleagues on your bad days and your good.

Bonus: While there are no ‘stupid questions,’ seek an answer before asking the question. Make an effort. Shed the helplessness.

Advice is seldom welcome, and those who need it the most, like it the least. — Lord Chesterfield

What advice do you all have for us chief residents? Do you have any other ‘must-get’ advice that I missed?

7 Responses to “Top 21 Thoughts for ’21”

  1. Richard Abrams says:

    Dr. Shah,
    I occupied your position as chief resident at the University of Colorado 45 years ago. I wish someone would have offered the same advice to me then. I hope your wisdom is widely read. Brilliant!
    With sincere respect,,

    • Sneha Shah, MD says:

      Dr. Abrams,

      Your comment is too kind! Thank you. Feel free to disseminate to those who might find this helpful.


  2. oded zmora says:

    For residents and interns:
    Eat 3 meals a day.
    Make sure you see the sun every day
    When writing notes, remember you might need to read them at 3 AM.
    The first question to ask when doing an admission is: “Who is your primary care provider?”
    The first step for the patient to be discharged is getting out of bed.

    • Sneha Shah, MD says:

      Thanks for these pearls! I have recently recognized the importance of the PCP one and making sure I get that into each of my interviews.


  3. Brian Zack, M.D. says:

    A few favorite related quotations:
    1. From med school graduation speech: “Half of what we have taught you is wrong. Unfortunately we don’t know which half.”
    2. You can choose to be a specialist or a generalist. If you become a specialist, you will learn more and more about less and less until you know everything about nothing. If you become a generalist, you will learn less and less about more and more until you know nothing about everything.
    3. Better to remain silent and be thought a fool than to speak and remove all doubt. (Attributed to Lincoln and Twain; author unknown.)

    • Sneha Shah, MD says:

      Hey Dr. Zack, thanks for commenting.

      That Twain/Lincoln quote is definitely one of my favorites. And coincidentally, I just heard the first one yesterday so sounds like it’s going to be one I have to start working through. Better start figuring out my 50% soon…

      Sneha (a generalist) 🙂

  4. Jaspreet Kaur says:

    Great read, as a senior resident still very relevant advice. I love “Shed the helplessness”, will likely use while mentoring too.

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