Long road to a bright future

Published on June 19, 2013
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To gain a better understanding of what it’s like to be an intern, JAVMA went straight to the source and spent one day each with three interns in academic, exotic, and equine practice. Their stories are told in the following articles.

Dr. Rickard Kohler ambles down the long white hallway on his way to see Zippy the cat’s owners. As he passes by numerous rooms—each dedicated to one of the 18 specialty services at the University of Wisconsin-Madison Veterinary Medical Teaching Hospital—his steps make the only sound, save for an occasional bark from the dog receiving dialysis in the critical care unit.  

By the end of his shift at 6 p.m., he’ll have seen only four patients today, Sunday, April 14, which he says isn’t uncommon. 

Dr. Rickard Kohler performs ultrasonography on Zippy the cat. Of the six critical care interns at the University of Wisconsin-Madison, five matched with residencies. Dr. Kohler begins his surgical residency in mid-July at the University of Minnesota.

“I feel like if you just want the experience, to see more cases, have someone supervise you, you might be better to do private practice, because you get more normal cases, more case responsibility, and probably a little higher caseload, depending on where you go,” he said. “We never really see the normal skin infections or stuff like that here.”  

Dr. Kohler, one of six rotating critical care interns, has a relatively predictable schedule: two weeks of daytime core rotations (such as internal medicine, surgery, and cardiology), from 8 a.m. to 6 p.m.; two weeks of emergency duty, from noon to 10 p.m.; one week of an elective, which can be anything from ophthalmology to tomotherapy to dentistry; and one week of overnight emergency duty, from 6 p.m. to 8 a.m., with the following weekend off. 

But in reality, he says, it sometimes feels like there are no set times. “You come and go when you’re done. The hours can be tough.”

Interns have teaching rounds in the morning, when faculty present cases, including patient histories and diagnostic test results, and go over the plan for the day. In addition, interns have their own rounds with other interns every Wednesday, when they present articles, are given a lecture on a variety of topics, or hold electrocardiography rounds or morbidity and mortality rounds. Every intern is expected to deliver a grand rounds presentation once a year.

After daily rounds, and depending on the service, the interns may see patients of their own, along with a student; talk with clients; and come up with treatment plans, after discussion with a resident or faculty member. At the end of the day, they typically have rounds with residents and faculty to discuss what they’ve done, go over test results, and develop plans for next steps.

On overnights, they start their shift by reviewing records of all the patients in the CCU and talking with the person in charge of each patient about the case plan and specific concerns. Then, they start seeing patients with appointments and walk-ins. Before leaving at 8 a.m., the intern again talks with faculty about what happened overnight.

During the day, there’s always a critical care resident on duty who is the first person called during an overnight shift if a complicated case comes in. If the resident needs guidance, the intern calls the criticalist for backup, or, if it’s an obvious surgery candidate, the surgeon.

“And then there’s obviously different opinions about how to run stuff, so sometimes you talk to (the resident or faculty member) and they want to do something different or transfer to a different service and they ask why you did this, but I think that’s normal. We tend to be very thorough, which I think is a good thing, but sometimes it’s a little frustrating, because there’s a lot of people and a lot of opinions,” Dr. Kohler said. 

Following a dream

Earlier in the day, critical care resi­dent Dr. Natashia Evans discusses with Dr. Kohler the history of Jack, a 7-year-old, three-legged dog, and his low neutrophil count. The two then go through the five body systems with fourth-year student Mindy Weseley in helping her determine what could be wrong with the dog. Following the impromptu lesson, Dr. Kohler and Weseley meet with Jack’s owners, Mark and Svetha Hetzler. Not finding anything substantially wrong with the dog, he prescribes antibiotics for an existing skin condition and tells the Hetzlers to come back in a week or two if the dog still isn’t doing well.

Although Dr. Kohler is working in critical care, his real passion is surgery. Early on, he got to know the hospital’s surgeons before he tried matching for a surgical internship or residency. He also asked to be on call during surgeries, even in the middle of the night, to show his enthusiasm.  

Unfortunately for him, the surgery section doesn’t give primary case responsibility to interns, unlike the medicine and critical care services. 

“The surgeons feel like the residents or (they) themselves should do the surgery, and by the time (patients) come here, they’re complex surgeries,” he said. The most experience he gets is supervising the students on spay and neuter days.  

Dr. Kohler has also shown enthusiasm for research. He’ll be a primary author on a paper reporting a study of iliopsoas muscle injuries in dogs. Within his first month, he had talked with a few surgeons about how to approach the study, and one surgeon mentored him through the process and will help him write the paper. On another paper, he’ll be a co-author. 

“Here at Wisconsin, they put a lot of emphasis on research,” he said. “That’s the main difference between private practice. There’s always stuff going on; private practice, not so much—maybe retrospective studies.”   

He chose an academic internship because he wanted to get exposure to a wide variety of cases and supervision by specialists in various departments. “But the ultimate goal was to optimize my chances for residency,” Dr. Kohler said. 

Knowing how competitive pursuing his goal would be, Dr. Kohler talked with the six surgeons at the hospital about what his approach should be. They told him to apply for residencies and internships at the same time, saying it’s great if he gets a residency, but most people don’t get one right away.  

“As far as I know—I’ve spoken to a few residency (proctors)—there were about 150 people applying for surgical residencies for a total of about 30 to 40 spots. Those numbers scare you and the fact that other people have done surgery internships,” he said.  

Yet, Dr. Kohler matched for a 3-year surgical residency with the University of Minnesota, which was among his top three picks. He begins in July.

Coming to America 

Meanwhile, Zippy the cat is dehydrated, straining to urinate, and vomiting. He has a history of chronic kidney disease. Dr. Kohler performs ultrasonography as the cat is held in place, and then tries to collect a urine sample from the cat, but has difficulty inserting the needle into the bladder. Dr. Evans steps in to take the sample and then advises him on a safer method of holding the cat. She recommends he practice by sticking a needle in Jell-O with fruit. 

Dr. Kohler, unlike most interns, has worked in private practice before. Originally from Helsingborg, Sweden, he worked at a clinic there for two years. Dr. Kohler said it was helpful to have been in private practice and now to be at the teaching hospital.  

“I don’t think we interns can complain, compared with my wife, who spent more time at her clinic during her internship (at a VCA hospital in Boston). 

“We have a decent amount of hours we work, but not too much. The hardest parts are the nights. Unfortunately, if you’re really busy, there are times when you have a lack of sleep, so you don’t function as good. I don’t think anyone looks forward to them, but then, it’s another chance for you to have primary case responsibility,” Dr. Kohler said.  

He arrived in Madison after a long journey. First, he moved back to the U.S. from Sweden in 2011 to marry his wife, Michaela, whom he had met while studying at the University of Georgia College of Veterinary Medicine. Dr. Kohler actually graduated from St. George’s University School of Veterinary Medicine in 2010. 

After they were married, Dr. Kohler couldn’t work, a stipulation in applying for a green card. So he spent many restless days in Florida while Michaela worked at an emergency clinic. They then moved to Wisconsin for his internship, and she found a job working on commission at a general practice four days a week in Madison. 

They both know a few more intense years remain ahead, but Michaela is pushing for children some day. 

They’ll have to figure out how to make that work and still have enough to pay off their $240,000 combined student debt on his $28,000 resident’s salary and her income, once she finds a position in Minnesota. 

“I don’t care about money, but it would be nice not to worry about it,” he said.   


To view additional photos of the interns at work, go to www.avma.org/javmaphotos for the online photo gallery titled “Day in, day out.”