Attending anxiety

[EthylMethylMan]

I just graduated residency in June and have been doing per diem ER attending shifts since. I'm doing them as a supplement to my non-ER fellowship, so I've only done two so far. They've gone fine, though the first and only code I've run so far as an attending ended unfavorably. I've mentally ran through the case a lot, and I'm pretty sure there's nothing else I could've done. Either way, I've had intermittent anxiety about doing more shifts since then. For those of you who have experienced this, does this anxiety get better with experience? Are there specific steps I should be taking? I've been studying a lot harder since graduation secondary to my anxiety and shift paranoia. Not sure what else do to besides maybe counseling.

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[RustedFox]

Bro, codes don't end favorably all the time.
The best advice anyone on here is going to give you is: "get a grip".

Sometimes, you need tough love.
This is one of those times.

 

[Mr. Vandemar]

As someone with no history of anxiety issues, I had straight panic my first few shifts and bad pre-shift anxiety for probably a couple months. Numbness sets in. In terms of a code, unless it was something uniquely traumatizing like a kid I’d just try to let that one go. There’s an algorithm we follow for those and it usually doesn’t work.

 

[s/p epilepticus]

Having a tough shift early on as an attending is like getting into your first minor car accident. You've got to drive asap afterwards so you don't get paralyzed with fear/anxiety the next time you get behind the wheel. Make yourself keep working shifts.

 

[Tiger26]

The first 6-12 months as an attending was way harder than residency. Way harder.

 

[WilcoWorld]

I just graduated residency in June and have been doing per diem ER attending shifts since. I'm doing them as a supplement to my non-ER fellowship, so I've only done two so far. They've gone fine, though the first and only code I've run so far as an attending ended unfavorably. I've mentally ran through the case a lot, and I'm pretty sure there's nothing else I could've done. Either way, I've had intermittent anxiety about doing more shifts since then. For those of you who have experienced this, does this anxiety get better with experience? Are there specific steps I should be taking? I've been studying a lot harder since graduation secondary to my anxiety and shift paranoia. Not sure what else do to besides maybe counseling.

I was a chief resident at a "powerhouse" residency and I am now an accomplished attending.

On the way to my first shift as an attending I had to get off my bike (ER doc through and through!) so I could wretch from all the anxiety I had.

What your experiencing likely doesn't indicate inadequacy - it indicates appropriate humility: good job.

 

[Groove]

It’s normal and will fade quickly. Most codes end poorly and the ones you do get back..don’t usually survive until discharge. It’s only the occasional and infrequent real “save”. Work on compartmentalization and…relax. If you weren’t ready for attendinghood, you wouldn’t be graduated, yeah?

 

[cyanide12345678]

I did moonlighting as a pgy3 at a single coverage shop where you could get destroyed and end up seeing 30-40 in a 12 hour shift. Always always felt anxiety about going to that place.

My first attending job i felt anxiety driving to the place for the first 1 month.

3 years in as attending, very sick crashing kids and OB deliveries make me anxious still. Disaster airways also still make me very anxious. Had a guy profusely bleeding through his trach site 2-3 weeks ago had me on edge for quite some time. All i could do was suction, hyperinflate trach balloon, give Txa, and beg Hospitals with ENT coverage to accept the guy.

 

[RustedFox]

I did moonlighting as a pgy3 at a single coverage shop where you could get destroyed and end up seeing 30-40 in a 12 hour shift. Always always felt anxiety about going to that place.

My first attending job i felt anxiety driving to the place for the first 1 month.

3 years in as attending, very sick crashing kids and OB deliveries make me anxious still. Disaster airways also still make me very anxious. Had a guy profusely bleeding through his trach site 2-3 weeks ago had me on edge for quite some time. All i could do was suction, hyperinflate trach balloon, give Txa, and beg Hospitals with ENT coverage to accept the guy.

Those things still make me edgy, and I'm 10 years out. Not getting ROSC shouldn't cause you an anxiety spiral... That's as common as an overthrow from 3rd to 1st base.

I had some new attending jitters. Some procedures still make me feel frustrated with their perceived simplicity but technical difficulty.

OP... it gets better fast.

 

[emergentmd]

ER medicine should weed out anyone with anxiety or fear of failing. If you have either, you could be in for a long road so first step is to choose a residency wisely. ER docs should be cold blooded multi-taskers, confident decision makers, realizing that all you can do is your best and not save everyone. ER docs should never be Monday morning QBs.

OP, I can't help you with this b/c I never had anxiety even on my first shift and maybe bc I did residency at a top 3 busiest trauma center in the US so I essentially saw/did everything as a resident.

To overcome your anxiety, you need to become that bolded person above otherwise you will have a tough ER career full of burn out. To your failed code, I would say my success rate in the over 60 year old population coding in the field leaving the ER is 10% and leaving the hospital close to 0%.

 

[Mount Asclepius]

I observed an wise, old geezer attending once tell an intern, “why are you running? The patient is having an emergency, but you aren’t.”

We often don’t have much control of outcomes. People that die often stay dead. Ones in purgatory often get there too, probably gladly.

Agree with @WilcoWorld above. Your experience is common and likely reflects your stage in development as an EP. It’s end of second year and early third year residents that ‘know’ what they are doing at all times. Then you come back down to reality as your ability level grows into realizing that you don’t know it all.

I also agree with @Tiger26, the first few months out of residency are the most challenging time you will experience in your medical training/career. The buck now stops with you for the very first time. That is daunting, but you are ready if well trained. Doesn’t mean it is easy. With time though it becomes second nature. Almost seamlessly you will transition from asking other colleagues for their second opinions to becoming the one your colleagues ask for a second opinion.

@cyanide12345678 and @RustedFox are also spot on. Delivering a baby no matter how routine, calming a frantic parent while you calm yourself taking care of a crashing kid, or drawing deep from your bag of airway tricks will always continue to make you pucker a little and clean up your pants later. The dead though, are dead, meh.

Everyone has felt some sense of anxiety during their career, even those who are calm, very even-keeled people. Those that can’t admit that are dangerously arrogant and poorly self reflective.

Climb back on the horse. One shift at a time. You’ll develop expertise (right before you burn out and pursue your non-ED fellowship full time). All the best.

 

[RustedFox]

Honestly, pursuing a non-ER fellowship is the single best thing OP can do.

I mentioned this in passing earlier, but I imagine one future (of many) where most EPs only work a handful (7-10?) shifts a month and all have a totally separate field.

 

[CoolDoc1729]

I just graduated residency in June and have been doing per diem ER attending shifts since. I'm doing them as a supplement to my non-ER fellowship, so I've only done two so far. They've gone fine, though the first and only code I've run so far as an attending ended unfavorably. I've mentally ran through the case a lot, and I'm pretty sure there's nothing else I could've done. Either way, I've had intermittent anxiety about doing more shifts since then. For those of you who have experienced this, does this anxiety get better with experience? Are there specific steps I should be taking? I've been studying a lot harder since graduation secondary to my anxiety and shift paranoia. Not sure what else do to besides maybe counseling.

I couldn’t find the room with the scrubs on my first day. That’s the only reason my first attending case wasn’t an unsuccessful code! This was ten years ago. My boss, who took care of it instead, has no recollection of this ever happening at all.
You need to add more to the “good catch” bank to compete with the “crappy outcome” bank in your mind. If possible it might actually help to pull more shifts for the next few months, honestly.

 

[WilcoWorld]

ER medicine should weed out anyone with anxiety or fear of failing. If you have either, you could be in for a long road so first step is to choose a residency wisely. ER docs should be cold blooded multi-taskers, confident decision makers, realizing that all you can do is your best and not save everyone. ER docs should never be Monday morning QBs.

OP, I can't help you with this b/c I never had anxiety even on my first shift and maybe bc I did residency at a top 3 busiest trauma center in the US so I essentially saw/did everything as a resident.

To overcome your anxiety, you need to become that bolded person above otherwise you will have a tough ER career full of burn out. To your failed code, I would say my success rate in the over 60 year old population coding in the field leaving the ER is 10% and leaving the hospital close to 0%.

This was not how my story went. OP - YMMV

 

[Arcan57]

Feeling anxious is a reasonable response to the experience of being a new attending in the ED. 3 years is obviously not enough time to learn the entirety of management for the pathology that presents to the ED. If it helps, you're extraordinarily unlikely to screw up on the big stuff any worse than anyone else. Follow the patients you admit, call people back you were a little worried about, and be a little more cautious than you were when you were a senior. Most people reach some equilibrium between their actual capacity to handle the ED and the inevitable habituation to risk.

 

[Lexdiamondz]

Bro, codes don't end favorably all the time.
The best advice anyone on here is going to give you is: "get a grip".

Sometimes, you need tough love.
This is one of those times.

Agreed.

We all have those days, but this is the job we signed up for. It's important to reflect and decompress but gotta keep it moving

 

[Tenk]

The only codes that end poorly are pediatric codes that don’t make it and that’s because it’s hard when kids die. If that happened, I’m sorry but you just have to give it your all on these and don’t hold back.

If this were an adult patient then the code went fine. Most people who code, die. It’s probably for the best because even if you get ROSC, most of them never return to their former self. When you look at a patient, ask yourself, what are we bringing back? A 70 year old overweight copd with multiple heart problems who now has hypoxic brain injury, kidney injury, and cardiac injury with multiple broken ribs on a ventilator? Sometimes dead is better.

 

[RustedFox]

The only codes that end poorly are pediatric codes that don’t make it and that’s because it’s hard when kids die. If that happened, I’m sorry but you just have to give it your all on these and don’t hold back.

If this were an adult patient then the code went fine. Most people who code, die. It’s probably for the best because even if you get ROSC, most of them never return to their former self. When you look at a patient, ask yourself, what are we bringing back? A 70 year old overweight copd with multiple heart problems who now has hypoxic brain injury, kidney injury, and cardiac injury with multiple broken ribs on a ventilator? Sometimes dead is better.

That last paragraph... so much truth.

If only the general population could read it and think: "I don't want to end up like that; I had better do SOMETHING now to get fit."

 

[vm26]

That last paragraph... so much truth.

If only the general population could read it and think: "I don't want to end up like that; I had better do SOMETHING now to get fit."

Spot on

 

[oldtown]

It’s normal and will fade quickly. Most codes end poorly and the ones you do get back..don’t usually survive until discharge. It’s only the occasional and infrequent real “save”. Work on compartmentalization and…relax. If you weren’t ready for attendinghood, you wouldn’t be graduated, yeah?

We don’t know if OP did a HCA residency though, do we?

 

[GonnaBeADoc2222]

Normal to be anxious.

I would expect this to last around 1 year, on average.

If you're not anxious in the beginning, it means you're not vigilant and not taking this seriously.

Don't listen to anyone above saying otherwise.

 

[Kryptocoin]

It's ok to have 1st year attending "jitters". Full-blown panic attacks are another story and could indicate a lack of preparedness during residency.

Things to do to ensure a successful attending transition:
1) Try to see everything you can during residency, especially trauma and peds. I ran so many ped codes during residency that I no longer have PTSD doing them as an attending. I've had colleagues that had to "time off" after a peds code. It never gets easy, but your mental health doesn't have to suffer.

2) Moonlight, moonlight, moonlight. Not in some sh*tty urgent care but a real ER where you're seeing and dispo'ing sick pts on your own. Big confidence builder.

3) Train at a program where you're basically functioning as an attending in your 3rd year. These are usually old established programs in resource-poor communities (aka county).

 

[Groove]

We don’t know if OP did a HCA residency though, do we?

Oh, I dunno how much that stuff really matters in the end. I work with a bunch of new grads that graduated from a residency that is fairly new-ish. I come from a traditional level 1 trauma center, big academic institution that was 100% resident driven. I'd call it a very traditional EM residency experience. Kind of surgery culture, very military and strict, no nonsense. These guys/gals come from a very different residency than what I'm used to... Very millennial friendly, "attending is your friend" mentality, plenty of safe places. Rotations are in a hodgepodge of institutions nearby. Most of the EM rotations are in community and tertiary care centers that are not trauma designated in our state. They have limited rotations at our local trauma center. Some isolated Peds rotations at our comprehensive peds center. They are kind of farmed all over the place. None of the EM environments are 100% residency driven. So, when they are on shift they are picking up pt's and co-managing with the attendings or simply watching us manage our own patients. It's really bizarre to what I experienced and when I first started working here I was honestly kind of skeptical that this type of environment could produce quality EM docs. However, as more and more have graduated and joined us, I've come to the realization that much of what makes a person a quality EP probably has more to do with the person and less about where they trained. These docs are some of the strongest EM docs I've ever worked with and it's got to be the individual. Either that or maybe people can thrive more than we think in non traditional EM educational environments. Who knows.

That's not a defense of the HCA residency issues and/or CMG sponsored residencies. I still don't support this push to glut the market with EPs using non traditional/community EM sites. But....maybe if you're a person that found yourself matched into one of these residency programs. Maybe, just maybe... you're not so screwed after all.

 

[oldtown]

Oh, I dunno how much that stuff really matters in the end. I work with a bunch of new grads that graduated from a residency that is fairly new-ish. I come from a traditional level 1 trauma center, big academic institution that was 100% resident driven. I'd call it a very traditional EM residency experience. Kind of surgery culture, very military and strict, no nonsense. These guys/gals come from a very different residency than what I'm used to... Very millennial friendly, "attending is your friend" mentality, plenty of safe places. Rotations are in a hodgepodge of institutions nearby. Most of the EM rotations are in community and tertiary care centers that are not trauma designated in our state. They have limited rotations at our local trauma center. Some isolated Peds rotations at our comprehensive peds center. They are kind of farmed all over the place. None of the EM environments are 100% residency driven. So, when they are on shift they are picking up pt's and co-managing with the attendings or simply watching us manage our own patients. It's really bizarre to what I experienced and when I first started working here I was honestly kind of skeptical that this type of environment could produce quality EM docs. However, as more and more have graduated and joined us, I've come to the realization that much of what makes a person a quality EP probably has more to do with the person and less about where they trained. These docs are some of the strongest EM docs I've ever worked with and it's got to be the individual. Either that or maybe people can thrive more than we think in non traditional EM educational environments. Who knows.

That's not a defense of the HCA residency issues and/or CMG sponsored residencies. I still don't support this push to glut the market with EPs using non traditional/community EM sites. But....maybe if you're a person that found yourself matched into one of these residency programs. Maybe, just maybe... you're not so screwed after all.

I was kind of just making a joke based on the other thread thrashing HCA residents/residencies.

Personally, I know exactly 1 EP who trained at an HCA residency and he’s a really good doc. Otherwise, all I know about them is hearsay from this place.

 

[emergentmd]

I trained a shock trauma site where everyone on here will know. 20 yrs ago, residents ran the place, attendings were essentially gone on most services other than the ED but even then, they didn't care much what you did.

I will always recommend a true county trauma center over community any day. Residency is where you should/need to handle exotic/sick pts where support is thin as getting this exposure as an attending is very difficult.

I also will say I moonlighted since PGY2 and recommend as much moonlighting as you can. I prob did over 1k Hours of moonlighting, Get your feet wet, it will make you a better PGY3. If you get enough moonlighting under your belt, PGY3 is essentially an attending year

There are plenty of great community residents who become great attendings. But all things being equal give me the guy from a trauma county with lots of moonlighting over a guy from an HCA high metric facility who just takes 60% UC and 30% belly/chest pain.