When am I supposed to learn this stuff?

[NWwildcat2013]

I am on my first hardcore inpatient rotation. I did really well on Step 1 and I scored >95th percentile on my previous two shelves, but I continuously feel like I am never asked any questions that I know. Should I know about how to manage electrolytes with fluids or what type and rate of fluid certain patients should be getting? I am getting really nervous because I am continually at a loss for almost all of the pimping questions on management, and I feel like I'm expected to know it.

Am I? If not, when does this transition occurs and how do you learn it? Im starting to think maybe its ok for me to not know and this is just how you learn it. Slowly, painfully, and by immersion. Unfortunately, my team makes me feel like I should know many of these things. Part of that may be due to lack of awareness of when the year switched and med students are MS3's and not MS4's. I just don't really see those nitty gritty daily management details in UWorld or Step up to Medicine.

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[Psai]

You just started your clinical experience, it would be surprising if you did know what to do. I still don't really know what I'm doing and look forward to making a lot of really stupid mistakes. You don't really notice that you're learning stuff but you are. I realized how much I knew at the beginning of M4 when I was on a team with an M3 and I was like wtf why don't you know any of these things? You just take it for granted because it comes easily with repetition.

For basic things like electrolyte management you will learn in lecture but there are a lot of free videos and podcasts online. People rave about online meded, I thought it was okay. I like emcrit.

 

[Bobcat18]

I feel the same way- you are not alone.

 

[lymphocyte]

I am on my first hardcore inpatient rotation. I did really well on Step 1 and I scored >95th percentile on my previous two shelves, but I continuously feel like I am never asked any questions that I know. Should I know about how to manage electrolytes with fluids or what type and rate of fluid certain patients should be getting? I am getting really nervous because I am continually at a loss for almost all of the pimping questions on management, and I feel like I'm expected to know it.

Am I? If not, when does this transition occurs and how do you learn it? Im starting to think maybe its ok for me to not know and this is just how you learn it. Slowly, painfully, and by immersion. Unfortunately, my team makes me feel like I should know many of these things. Part of that may be due to lack of awareness of when the year switched and med students are MS3's and not MS4's. I just don't really see those nitty gritty daily management details in UWorld or Step up to Medicine.

1. You're not expected to know it. You're expected to learn it. That's the most helpful/sanity-preserving perspective, even if it's not true.

2. Making students feel dumb is considered a rite of medical education; it serves a motivational purpose. It still sucks, and things should probably be done differently. I'm sorry that you're having a rough time. If it helps, everybody suffers through it. You are definetly not alone.

3. Sometimes appearing thoughtful for a second and saying, "I don't know but let me look that up"--and then looking it up--is the best you can do. If you don't know, you don't know. No point in getting nervous about it (as long as you work hard to plug the gaps in knowledge). Every year, at hospitals around the country, there's a bolus of clueless medical students, clueless interns, clueless first-year attendings--they're all just clueless about different things. So it goes.

4. Learning does and doesn't come by immersion. You certainly learn lots of medicine by doing and deliberately reflecting ("what did I see"?, "why did they do that"? "what makes this resident so efficient"?), but you also have to aggressively learn a lot on your own.

5. UCSF Hospitalist Handbook + Mass Gen Handbook + UpToDate. The Hospitalist Handbook is the most "nitty gritty" with all kinds of neatly-organised practical tips and order sets. Apple or Android. Mass Gen Handbook is more detailed and good for ward downtime. UpToDate 30 minutes a night no matter how tired you are. Just pick a topic common to several patients under the care of your team. If you use all three resources consistently, you'll learn and learn and learn until things seem like second nature--especially the practical stuff you don't get in textbooks.

 

[cbrons]

I am on my first hardcore inpatient rotation. I did really well on Step 1 and I scored >95th percentile on my previous two shelves, but I continuously feel like I am never asked any questions that I know. Should I know about how to manage electrolytes with fluids or what type and rate of fluid certain patients should be getting? I am getting really nervous because I am continually at a loss for almost all of the pimping questions on management, and I feel like I'm expected to know it.

Am I? If not, when does this transition occurs and how do you learn it? Im starting to think maybe its ok for me to not know and this is just how you learn it. Slowly, painfully, and by immersion. Unfortunately, my team makes me feel like I should know many of these things. Part of that may be due to lack of awareness of when the year switched and med students are MS3's and not MS4's. I just don't really see those nitty gritty daily management details in UWorld or Step up to Medicine.

Two choices:

1. You will learn passively through your clinical experience (very, very slow way of doing it, won't be efficient, and you won't be ready for residency, and essentially will have to have your hand held).
2. You can read on your own. I mean, not just reading for what is on the shelf exam, but reading for how to actually be a doctor.
https://www.amazon.com/Principles-Practice-Hospital-Medicine-Sylvia
https://www.amazon.com/Harrisons-Principles-Internal-Medicine-Vol-1/
http://lifeinthefastlane.com/ccc/
https://www.acadoodle.com/ [ekg]
https://www.amazon.com/History-Physical-Examination-Clinical-Strategies/ (must have book that will you give the questions you need to ask when doing your H&P and the info you need in your presentations).
Also Pocket Medicine and Washington Manual but of course those are just quick references.


The big mistake I see is M3s just studying from Step Up To Medicine. All that is just memorizing some factoids, none of which you understand, to regurgitate on an exam.

 

[nlax30]

I think just about every intern feels the same way starting off. You now have more responsibility, work longer hours AND basically now get to learn HOW to be a doctor.

I know I felt the same way during most of intern year. Usually it felt like I was just trying to get through the day, not overtly kill anyone and pick up some nuggets here and there. Obviously your program should have some sort of scheduled/protected didactic time during the day and then it's up to you to carve out a little time here and there to read.

I agree with the above in finding a few sources that you can tolerate reading and use those. During my IM training I liked the Washington Manual series. I also found a few medical podcasts that I enjoyed and would listen to in the car.

For me there wasn't a specific time during intern year where it just clicked and I automatically felt comfortable and at the time I didn't feel like I was actually learning anything. I think you'll look back at the end of the year and realize just how much you've picked up and learned.

 

[Crayola227]

I think just about every intern feels the same way starting off. You now have more responsibility, work longer hours AND basically now get to learn HOW to be a doctor.

I know I felt the same way during most of intern year. Usually it felt like I was just trying to get through the day, not overtly kill anyone and pick up some nuggets here and there. Obviously your program should have some sort of scheduled/protected didactic time during the day and then it's up to you to carve out a little time here and there to read.

I agree with the above in finding a few sources that you can tolerate reading and use those. During my IM training I liked the Washington Manual series. I also found a few medical podcasts that I enjoyed and would listen to in the car.

For me there wasn't a specific time during intern year where it just clicked and I automatically felt comfortable and at the time I didn't feel like I was actually learning anything. I think you'll look back at the end of the year and realize just how much you've picked up and learned.

they're MS3, but yeah

 

[Crayola227]

Two choices:

1. You will learn passively through your clinical experience (very, very slow way of doing it, won't be efficient, and you won't be ready for residency, and essentially will have to have your hand held).
2. You can read on your own. I mean, not just reading for what is on the shelf exam, but reading for how to actually be a doctor.
https://www.amazon.com/Principles-Practice-Hospital-Medicine-Sylvia
https://www.amazon.com/Harrisons-Principles-Internal-Medicine-Vol-1/
http://lifeinthefastlane.com/ccc/
https://www.acadoodle.com/ [ekg]
https://www.amazon.com/History-Physical-Examination-Clinical-Strategies/ (must have book that will you give the questions you need to ask when doing your H&P and the info you need in your presentations).
Also Pocket Medicine and Washington Manual but of course those are just quick references.


The big mistake I see is M3s just studying from Step Up To Medicine. All that is just memorizing some factoids, none of which you understand, to regurgitate on an exam.

Harrison's is a bad choice IMHO

 

[nlax30]

they're MS3, but yeah

Ahhh, reading comprehension fail. What I said still applies, somewhat, kind of...... in a generic/vague way. Eh, they'll be fine.

 

[dozitgetchahi]

Harrison's is a bad choice IMHO

Yeah, don't go reading Harrison's as an MS3 on IM. That's a great way to get totally overwhelmed and behind, fail the shelf and end up totally screwed.

If you truly know everything in Step Up to Medicine as an MS3, bravo. I'd actually say that's pretty good. If only every incoming intern knew everything in Step Up to Medicine on day 1 of residency...

 

[Crayola227]

I liked the student MKSAP I'm surprised it hasn't come up here....

 

[cabinbuilder]

Yeah, don't go reading Harrison's as an MS3 on IM. That's a great way to get totally overwhelmed and behind, fail the shelf and end up totally screwed.

If you truly know everything in Step Up to Medicine as an MS3, bravo. I'd actually say that's pretty good. If only every incoming intern knew everything in Step Up to Medicine on day 1 of residency...

I think Ferri is a much better choice, gives you what tests you need and treatment plans for anything IM.

 

[JustPlainBill]

I am on my first hardcore inpatient rotation. I did really well on Step 1 and I scored >95th percentile on my previous two shelves, but I continuously feel like I am never asked any questions that I know. Should I know about how to manage electrolytes with fluids or what type and rate of fluid certain patients should be getting? I am getting really nervous because I am continually at a loss for almost all of the pimping questions on management, and I feel like I'm expected to know it.

Am I? If not, when does this transition occurs and how do you learn it? Im starting to think maybe its ok for me to not know and this is just how you learn it. Slowly, painfully, and by immersion. Unfortunately, my team makes me feel like I should know many of these things. Part of that may be due to lack of awareness of when the year switched and med students are MS3's and not MS4's. I just don't really see those nitty gritty daily management details in UWorld or Step up to Medicine.

You're probably right at the point you're supposed to be at --- a lot of this isn't taught in medical school and you get punt-kicked into the big bad world the hospital without any real instruction in this type of stuff --- I agree with the advice to learn it now, because you will get shark attacked as an intern if you don't know it (at least I did) -- it's not fun.

Little secret -- as a student,you're not expected to know it -- as a physician at any level (some places are more malignant than others), you're expected to --- so, try this -- when you get pimped into submission, write down what they were asking about and go look it up in your downtime -- write down the answer and then when the team has downtime, ask about it -- it'll do 2 things -- show you're interested in learning, be helpful in creating confidence in the interns (hey, I do know the answer) as they can learn from it without having to look dumb in front of the seniors/attending, and you'll actually get a "yep, that's how it works" or "No, close but here's the real deal" answers in a setting where you can't be blamed for not knowing it.

In my medical school, I was told that we'd learn treatments as interns -- but then I went to a malignant residency (unknown to me at the time) that expected you to know everything about every rotation before you started the rotation -- the concept of training was lost on them.

 

[scpod]

I am on my first hardcore inpatient rotation. I did really well on Step 1 and I scored >95th percentile on my previous two shelves, but I continuously feel like I am never asked any questions that I know. Should I know about how to manage electrolytes with fluids or what type and rate of fluid certain patients should be getting? I am getting really nervous because I am continually at a loss for almost all of the pimping questions on management, and I feel like I'm expected to know it.

Am I? If not, when does this transition occurs and how do you learn it? Im starting to think maybe its ok for me to not know and this is just how you learn it. Slowly, painfully, and by immersion. Unfortunately, my team makes me feel like I should know many of these things. Part of that may be due to lack of awareness of when the year switched and med students are MS3's and not MS4's. I just don't really see those nitty gritty daily management details in UWorld or Step up to Medicine.

As a medical student you will never be tested on dosing and specifics. But once you become and intern you have to hot the floor running. Just looking at this question, fluids are one of the things that tend to get looked over sometimes, but they should be treated just like any medicine you give to a patient. You can do a lot of damage with fluids if you don't know what you are doing. Back when I was chief resident, that was once of the lectures that I gave very early on because it's importance if often overlooked. For now, though, there are a lot more things to concentrate on. You may never get tested on this.

 

[tvb]

Bro at least you're getting asked questions that you'll eventually need to know. The other day an oncologist told me a patient had a very specific and rare cancer that failed conventional treatment and in the same breath they asked my what the preferred chemo regimen would consist of. How in the f*ck would I know that?

 

[NWwildcat2013]

In talking with my peers it seems what I feel I am not learning are all things that are taught during medicine. I was thinking it'd be nice to have IM last (which I do) because all of that material will be fresh for Step 2. However, Im going to go through this entire year pretty clueless about a lot of basic medicine topics and Ill need to pick them up either on my own or piecemeal from other services. Its frustrating because I can already see the people who have done IM being more competent about basic things. Also at my school, IM is the service where you truly learn how to write a good note and formulate and A/P, so I am feeling very behind.

 

[theseeker4]

In talking with my peers it seems what I feel I am not learning are all things that are taught during medicine. I was thinking it'd be nice to have IM last (which I do) because all of that material will be fresh for Step 2. However, Im going to go through this entire year pretty clueless about a lot of basic medicine topics and Ill need to pick them up either on my own or piecemeal from other services. Its frustrating because I can already see the people who have done IM being more competent about basic things. Also at my school, IM is the service where you truly learn how to write a good note and formulate and A/P, so I am feeling very behind.

You could say something like this about just about any order of specialties in third year that you can think of. The person with surgery and OB/gyn last goes through 3rd year unable to throw a simple stitch. The patient with peds last goes through third year without any clue about caring for children. The person with psych last has no clue about basic management of psychiatric conditions. The person with neuro last won't know how to do a stroke scale if asked to do one on the floor. Etc, etc, etc.

You feel like you are at a disadvantage because you see very clearly what you don't know yet. EVERYONE has a large list of things they don't know yet, but you just see what they do know and compare that to what you don't. It doesn't mean you are really at a disadvantage, as you are building lots of skills that will help you when you start medicine, even if it doesn't feel like it yet.

If you feel like you arent writing a good note, practice, and get feedback. Just because you are on surgery, for example, doesn't mean you can't write a good note or get ideas for improvement. One way to do this is, when you are on surgery, look at some notes written by medicine about your patient. Compare their H&Ps to ones you have/would write, and see where you can improve. You will also notice a lot of mistakes that the residents who are writing notes are making, and you can learn from those too. This has the added advantage of you learning more about your patient's medical history and prior problems than simply doing an H&P would allow you to do. Doing this will allow you to improve your medical knowledge, improve your note-writing skills, and help you impress your residents/attendings when you know everything about your patient.