DancingFajitas

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Just wondering if anyone else is having trouble taking book knowledge and making it work for you in clinic/ on the wards? I find that it is super easy for me to interview a patient and have some kind of idea as to what is going on, but then I just kind of shut down when it comes time for differentials and planning tests, confirming dx, etc...Does anyone else have this problem? I especially think it is hard in clinic because as soon as you walk out of the room, the attending is looking at you ready for a presentation complete with differentials and treatment plans. My mind gets boggled. Any ideas on how to fix this?
 

vtucci

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I have not had this problem during third year but I think one of the keys to success is writing down as much information as possible while interviewing the patient so as to provide an organized approach to your presentation including DDx and A/P.
 

smq123

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Just wondering if anyone else is having trouble taking book knowledge and making it work for you in clinic/ on the wards? I find that it is super easy for me to interview a patient and have some kind of idea as to what is going on, but then I just kind of shut down when it comes time for differentials and planning tests, confirming dx, etc...Does anyone else have this problem? I especially think it is hard in clinic because as soon as you walk out of the room, the attending is looking at you ready for a presentation complete with differentials and treatment plans. My mind gets boggled. Any ideas on how to fix this?
How long have you been on rotations for? (i.e. are you one of the second years who just started, or have you been on the wards for a while?)
 
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DancingFajitas

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i've been on a while..i just dont think i'm where i need to be..but sometimes when i look around at my peers, i dont think they are there either..i was just wondering if anyone else was experiencing this or not.
 

fang

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Show me an MS3 who thinks they can spew out a detailed, correct assessment and plan with no help from me or anyone else, and I'll show you an over-arrogant student with a big surprise coming up on his or her eval. Seriously, you shouldn't feel bad at this stage about not knowing the next step. The important thing is to push yourself to try. Do the information gathering, and then leave 2-3 minutes after you leave the room (or before if your preceptor hangs around outside the door) to quickly think about or look up the patient's problem. You could use UTD or diagnosaurus, or run through the VINDICATE categories. If you get nervous when you get to that section during the presentation, think of a basic template you can run through in your head:
1. pt age, pertinent PMHx and CC
2. 2-3 top likely causes
3. 1-2 rare but potentially life-threatening causes
4. w/o for above-- think about labs, rads
5. treatment for above (even basic suggestions... antibiotics? steroids? joint injection?)
6. treatment of symptoms (general categories: treat pain? needs work note?)
7. when to follow up
If you even come up with a just few words for each of the above, that's actually a lot. If you're off base or have no idea what the treatment is, now is your opportunity to learn! Here's an example:

54 y/o with past MI, here with non exertional left chest pain after trauma, now resolved. The description sounds most like musculoskelletal injury, but GERD is also possible and it would be important not to miss a cardiac source. We could get an EKG and CXR in the office today, make sure he's taking all his cardiac meds, and suggest acetaminophen for pain. If it doesn't resolve he should come back in 2 weeks, and if it gets worse or he gets short of breath or diaphoretic with the pain he should go to the ED.

Hope that helps.
 

vtucci

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i've been on a while..i just dont think i'm where i need to be..but sometimes when i look around at my peers, i dont think they are there either..i was just wondering if anyone else was experiencing this or not.
You are not alone. I have heard many students complaining about this.

Sometimes it is just blanking out in front of the attendings. Almost everyone has experienced that sensation at one time during clinicals. Some of the attendings I know have said that they expect this to a certain extent from students and are used to it. They call it the deer in the headlights phenomenon. It does not reflect badly on us as students when it happens. Part of the system is trying to get us to think on our feet and multitask in preparation for practice. Most attendings are not malicious and as students, we all adapt to this at different paces.

I think Fang is right. Residents and other staff can be a great resource to bounce ideas off of if the time allows. If there is no one to bounce things off of other than the attending as is often the case in primary care, I have taken to trying to be as organized as possible and then trying to come up with a DDx and an A/P on my own. I am not concerned at this stage of training at getting out there on that edge and looking stupid. I would rather take the risk, make the mistake and remember what I did wrong than expect others to spoon-feed me and not know critical information down the road. IF I am wrong, I will humbly admit it and know better next time.

I would not worry if I were you. We are supposed to be our own toughest critics. The moment we stop learning, we die.
 
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DancingFajitas

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Thanks guys! Its nice to hear the truth from someone instead of people on here just being arrogant. I appreciate the advice and I will definately use it. Any other advice is appreciated! Thanks.
 

roja

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No one expects an MS3 to give a great differential and treatment plan. Critical thinking and diagnostic/treatment skills take time to learn. You need to practice.

So, gather all the information. Put it in an organized format and ATTEMPT to come up with a differential and plan. Its the act of trying and process (and being wrong and learning from it) that will make you better at this.
 

lil pook

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its okay.

look....reciting what you think the problem may be and how to solve it in front of an attending is intimidating...espec when they already know the answer,and are sitting there with a smug expression on their face.....that is part of the mind*uck of third year...get used to it.


the best you can do is just give it a go and have a reason why you wanna do what you wanna do.

g'luck
 

persia

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In the begining medicine can seem like a cookbook, and you are just trying to make something. Pancreatitis, acute: add IV fluids, NPO, pain killers, check labs, etc.

Sometimes just having a good diagnostic book can be a huge help. I mean, do you really know how to make a seven-layer cake? No? then read a cookbook.

Try things like pocket Harrisons, or Cecils, uptodate or any other clinical diagnostic book/tool you like. It will teach you clinical signs, how to rule in/rule out, and then how to treat including the almighty and most important - antibiotics. ;)

Just trust the book and go with it, there is no way you will already know this stuff, it takes years to get good at it. Just keep trying and it will eventually feel easier.