confidence to treat patients?

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I was just wondering when med students generally gain confidence to treat patients? i'm starting med school in aug. and I feel like there's no way i can ever be able to diagnose everything. i've volunteered at hospitals before and see all the docters perform their duties like its routine. when will i get that kind of confidence?

Ummm, I start third yr rotations next week and my level of confidence is at 0 too so I think that you are still in better shape then I am. I suppose that my level of confidence in dealing with patients was running in the negative numbers throughout my pre-clinical years, so 0 is probably an improvement for me. <img border="0" title="" alt="[Wink]" src="wink.gif" />

My goals for third yr:
-Do no *permanent* harm
-Try to learn as much as I can for when I have to do this stuff by myself
-Pass

If I were you, I would just worry about doing well in your classes and passing the boards. Any patient care experiences you have are just gravy in your training; you really don't have to worry about the clinical years until 3rd yr and then most people worry abou it anyways.

It depends on what you mean. If you mean...pt Smith has these UTI symptoms...every 3rd yr knows (or should know) what to do. On the other hand, if you mean, "pt Smith is unresponsive, or seizing, or droping his pressure, or, droping his sats, or being combative etc., etc.!", I'd have to say that kind of confidence doesn't usually kick in until about midway through internship.

Hey Guys,
Relax! Your medical school curriculum is designed so that you are never in over your head unless you take it upon yourself to do something stupid. You have more senior medical students, interns and residents who are doing more advanced things. If you are beginning medical school, focus on mastering those thousands of factoids that first and second year will throw your way.

If you are just starting your third year, observation is your main job. Watch your interns and residents. Learn how to make clinical observations. Learn how to present patients well. Practice doing an excellent history and physical. Know more about your patients than anyone else on the team and communicate well with your interns. Read about your patient's conditions and keep up with your reading for your rotational exams. For me, things really started to click about halfway through my first rotation during third year. I started with pediatrics, which is less malignant than medicine, and just got into the timing of rounds etc. You admit patients, you do your ward work, you get your patient care duties done, you read in your down time, you call home etc. You just start to get a flow.

During fourth year, you start to develp a style of practice. Are you more analytical and standoffish or are you pretty hands-on with the patients. Much of your practice style has to do with your personality style. I have met few pediatricians that were not "big kids" themselves. Many surgeons tend to be pretty impatient with very high energy levels. Many internists are very analytical and like to discuss differential diagnoses.

Relax and try to enjoy your medical school experiences. The years will fly by and you will be ready for each next step as it comes. The interesting thing about medicine is that you adjust to all the changes or you leave it before you really take on serious patient-care responsibility.

njbmd

with what njbmd has said.

i just started my M3 year 2 weeks ago. although outpatient stuff is pretty tame, you still are unsure what to do. however, as days go by, you do get used to the "flow" (to borrow njbmd's term) of the way things are run and more of the pesky things like where scripts are, where radiology request forms are or lab forms, how to discharge a pt. from clinic, how to type and send a note to an attending on the hospital computer system, etc.

right now, i think the expectations are pretty decent. none of the attendings so far have really made us feel stupid and know that we can't come up with a decent treatment plan all by ourselves. mostly, there are residents around you who can help, especially if you're paired with them to see a pt. or handle a half-day of clinic. you become an ally with them if you do your job and don't whine or suck up too much.

always ask questions...i was a little intimidated by doing so, but it will only dispel the inevitable confusion.

in specialty clinics like oncology, the M3 can't do a lot except tag along with a resident or the attending. however, they do go over the physical exam with you, pertinent labs, the grading of tumors, and what the treatment plan is. this is all you need to know for such a narrow, specific field at this stage; most people really don't get much more knowledge in oncology unless they do a fellowship.

there are enough checks and balances in place to prevent you from incurring horrendous mishaps. even the residents who see their own patients still must consult with attendings to discuss the pt's reason for visit, any findings in the exam or on labs, and what the plan is (i.e, they must get a seal of approval from the attending before they can proceed).

i know you may not be confident about surmising a diagnosis or plan, but when you write a note or present it orally, offer it and the attending will correct you but at least you're showing some effort and thought process.

as M3's, for sure we won't know how to handle codes or such emergencies, so you're limited to following up on patients, their labs, the orders, and helping the service or team out as much as you can. that does set up some scut work potential, but so far it really hasn't happened. i really don't find filling out forms and scripts to be scut work because, as an intern, you'll have to do that by yourself anyway.

best o' luck,
-s.

Hi-
Cool thread- I remember thinking those same things when I was in your position(s). Here's my $0.02 on what I found helpful in the first 3 years:

3rd year/Wards/Clinics- nice things to have with you:

1. Maxwell's Pocket Guide- a tiny pocket-sized book with tons of helpful things, like what to include in histories and physicals, how to write admission orders, how lab values are written, normal ranges for labs, and plenty of other things.

2. Either Mosby's or Washington's Manual- Great for (especially) Internal Med, helpful for nearly all rotations; these manuals have descriptions of a wide spectrum of diseases, differential diagnoses, treatments, and more. These are also pocket-sized; one of my favorite things to have handy in the hospital.

3. Drug books- Pharmacopeia and The Sanford's Guide to Antimicrobial therapy- some more pocket-sized books that are great medication references.

4. Several black pens

5. A pen light

6. A stethoscope

7. Palm Pilots- Many people love them; you can survive without one, and although I don't carry mine with me often (I spend a lot of time in the operating room and am not real crazy about leaving it laying around); I'd venture to guess that these are going to become a necessity in the years to come.

8. Surgical Recall for your surgery rotation(s).

9. A pair of scissors (for surgery, especially)

10. Some prescription pads


Freshman and sophomore years:

1. Learning how to budget time- The hardest thing for me- a habitual crammer in college, I found it very difficult to learn how to study for a test 4 weeks in advance. With the enormous volume of material presented to you, preparing for a test weeks in advance didn't sound so weird to me anymore. I learned eventually to keep up on classwork every night and it brought my grades from mediocre to straight A's.

2. Take preparation for Step 1 of the boards very seriously- doing well on the boards can do nothing but help you, even if you are applying for a less competitive residency. Topics from 2nd year of medical school are generally hit harder on Step 1, but don't forget to study things like Behavioral Science and Statistics. You may change your mind of what you want to specialize in dozens of times as you go through 3rd year, and in case you decide you want to go for something really competitive, you'll be in better shape if you have a high Step 1 score backing you up.


I think you are already in good shape; in my experience, the vast majority of people at the hospital would view your asking, "I don't know how to do/ don't feel comfortable doing that" as a sign of maturity and appropriate concern for patients and will be happy to teach you how to do it. People were generally eager to help me when I asked that, and in the situations where I can be of help now, I'm willing to do the same for the new students.

Good luck!

Alicia, MS IV
(going for general surgery)

From what I've observed, the feeling of "Oh my gosh I don't know anything" comes when you start each new step.

I experienced it last year when I started my M3 rotations. I got the hang of it pretty quickly, and got to be fairly comfortable with the role of the M3. Now I will soon start M4 rotations, starting with JI at other schools AND I will be wanting to do well enough to get Letters of recommendations from those rotations. So, again, I feel like I don't know enough to function at the next level, especially since several of them will include ICU time (and we don't get any ICU exposure during the 3rd year)

My friends who just graduated and started internship feel like they don't know enought to be interns. In fact, I saw one of them give a H&P to the resident for co-signature. He doesn't have to do that now, he's a doctor, but it's a reflex left over from student days.

Residents who just finished were nervous about going into private practice and not having the backup of an attending.

The whole medical education process is a cycle of learning how to handle one step, then moving up. Each move up brings nervousness. But the vast majority of people make it through successfully.

As a second-year student, we had a physical diagnosis course where we would go see a hospitalized patient, do a complete H and P (for practice only) and discuss it with a resident or attending preceptor in small groups of about 5 students. I had to look at my notes to even rememer what to ask on the history and what to do on exam. Back in those days, I had the same worries as you do now, but my preceptor once told us, "after 2nd and 3rd year of med school you basically keep learning the same stuff over and over in your training until you understand it at higher and higher levels, but its the same stuff." - kind of like how reading seemed so mysterious and hard in kindergarden, and now you can read college textbooks with ease.

First two years, get the background knowlege down.
Third year - start by learning what questions to ask patients that are most pertinent to their complaint, then what exam findings to look for that support or rule out the possibilities.
Fourth year (and late third year), start really pushing yourself to make clinical decisions on your own, then see if your diagnosis and treatment plans match the residents. Ask the residents how they came to their assesment and plans, and if yours differ ask them respectfully "what if.." questions about your ideas and get to learn the reasoning process (occasionally you might even help greatly by thinking of something that was not thought of yet)

I am amazed at how easily I can do a few H+P's now, and recite them from memory hours later, with understanding of the diagnosis and treatment plans - I could never have done that a year ago, but it's true what they say - practice makes perfect.

There is a ton to learn, but the structure is set up in this apprentship way that your leaning level should keep pace with your responsibility level just fine.

Interesting thread. I'm always reassured when someone seems uncertain of what s/he knows at each level of education. It's always better to have that initial doubt than to go in like "gangbusters" with a certain degree of overconfidence and get careless. It's the "cowboys" that truly give me the willies. As others have already posted, medical education is incremental: you know all you need to know, by the nature of the structure of your education, for that level. A PGY-1 just asked me the other day if I felt "stupid" when I first began my PGY-1 year. Of course. But without even realizing it, as you do the same procedures over and over again, you gain the confidence for the next time. Ironically, sometimes one can become too complacent and think that the case before him is just the same as those he had seen a dozen times prior, and in reality this one is totally different, just presenting similarly. This is truly one of the hardest things to realize about medicine: that sometimes what appears the same is truly different.

If you don't know: ASK! Remember the nurses! If you are uncomfortable looking ignorant in front of housestaff, a kindly nurse will show you how to do some of the procedures. They've been doing it for generations of medical students/interns, they have informed me. Remember the pharmacists! They, too, will save you hours of research if you give them a call. In general, remember the ancillary staff. Most are more than happy to help you out with your questions.

And finally remember: If you've gotten this far in your training, trust that you will complete it successfully. It's really about knowing the boundaries of your limitations and to keep on learning what you are uncomfortable with. Good luck!

Originally posted by 2003doc
Hi-
Cool thread- I remember thinking those same things when I was in your position(s). Here's my $0.02 on what I found helpful in the first 3 years:

3rd year/Wards/Clinics- nice things to have with you:

1. Maxwell's Pocket Guide- a tiny pocket-sized book with tons of helpful things, like what to include in histories and physicals, how to write admission orders, how lab values are written, normal ranges for labs, and plenty of other things.

2. Either Mosby's or Washington's Manual- Great for (especially) Internal Med, helpful for nearly all rotations; these manuals have descriptions of a wide spectrum of diseases, differential diagnoses, treatments, and more. These are also pocket-sized; one of my favorite things to have handy in the hospital.

3. Drug books- Pharmacopeia and The Sanford's Guide to Antimicrobial therapy- some more pocket-sized books that are great medication references.

4. Several black pens

5. A pen light

6. A stethoscope

7. Palm Pilots- Many people love them; you can survive without one, and although I don't carry mine with me often (I spend a lot of time in the operating room and am not real crazy about leaving it laying around); I'd venture to guess that these are going to become a necessity in the years to come.

8. Surgical Recall for your surgery rotation(s).

9. A pair of scissors (for surgery, especially)

10. Some prescription pads

I'd also like to add (mostly for Medicine, if you want to look like a star):

- A healthy supply of Guaiac cards, developer, and lubrication You generally have to search a few supply rooms before you find the developer.

- Mydriacil (get a resident to order it to bedside), as I've known some attendings wanting you to do a fundoscopic if indicated.

- A metal ring and hole-punched index cards to keep track of patient labs and info.

Let me add here... YOU are going to make mistakes, hopefully they will not be fatal. Example: 3rd resident hands you(PGY-1), a medication chart and you procede to follow HE'S orders, wrong, always double check everything!!! Gave the pt the medication and the pt had a re-action fairly quickly(thank goodness) and the mistake was corrected immediately. Thank God for nurses!!! They are going to save you more than once... you are written up and the 3rd resident goes scot-free, doesn't even come close to accepting any responsibility. And you can bet that will only happen to you once, never again. And more importantly if you ever do that to an intern you will handle it differently. Give me your opinion on how you would handle the situation.

There is a HUGE difference when you are totally held responsible for the total care of that pt and have to sign those forms for the first time and realize that person's life is in your hands. Make your mistakes in training!!! Few people in medicine admire incompetence, while most of your mistakes should be in procedures and not knowlege, take the time to gain the skills in both.

As a side note: my fellow intern I was referring to in the above scenario was depressed for a week about this. As a team we did everything we could to assure him ****happens, just never on our watch!!! Again!

2003 doc,
I am looking for a good pocket size diagnosis, tx, etc., book online. When you say Washington Manual, do you mean the Washington Manual of Medical Therapeutics? It says it has 697 pages though. I am not sure if this is the pocket size edition. Also, can you give me more info. about Maxwell's book?
Thanks!