About to graduate, feeling very nervous

[funnybanana]

Have a job lined up, graduating in a month. My program has put out solid graduates, but I’m feeling unprepared. As I get closer to finishing, I realize how little I know. What if I happen to freeze and call for the wrong medicine or dose on a critical patient? What if a trauma comes in and I’m solo coverage with nobody around to help? These are really frightening thoughts for me. Has anyone here felt similar?

---

Members don't see this ad.

 

[namethatsmell]

Totally normal and these thoughts/worries will keep patients (and you) safe as you enter attendinghood. It would be worrisome if you felt 100% confident coming out of residency, as nobody should be.

Everything will be a-ok.

 

[Mount Asclepius]

Yes. You’ll be fine. It’s far worse to think you know it all. Medicine is the hardest the first 3-6 months out of residency, but at the end of the day the medicine is the easier part of this job.

 

[Tiger26]

Normal to feel nervous but for me it wasn't about the critically ill. I think any residency graduate is going to be more than prepared. I felt the biggest knowledge gaps were about the minor and obscure stuff that residency doesn't prepare you for. For me, ortho concepts like knowing what's good enough and when to schedule follow-up were a dilemma. It's also the presentations like "my elbow hurts every leap year" or "I feel like the artery in my neck is numb." Mostly it was the WTF presentations that caused me a lot of pause right out of residency but I just accept as part of the job now.

 

[nVictus]

pretty normal to feel nervous for a new grad. some adjust in a few weeks, others take a few months.

it's one of those things where you can't 100% prepare, you just have to dive in and let experience do the work.

have comfort in knowing 90% of your shifts/patients are boring, you'll have time to adjust without many sphincter tightening moments.

 

[JacobMcCandles]

Totally normal. That nervousness and jitteriness before a shift will last a year or so but will go away. That doesn’t mean the learning stops, though. You’ll probably have more medical knowledge than many of your older colleagues but they’ll be a better doctor than you are. Learn from them.

 

[Apollyon]

Yeah there's mostly chaff with the rare wheat, but you're there to pick that out. The funny thing is, when it happens, you'll happily surprise yourself that you know exactly what to do!

 

[bravotwozero]

Normal to feel nervous but for me it wasn't about the critically ill. I think any residency graduate is going to be more than prepared. I felt the biggest knowledge gaps were about the minor and obscure stuff that residency doesn't prepare you for. For me, ortho concepts like knowing what's good enough and when to schedule follow-up were a dilemma. It's also the presentations like "my elbow hurts every leap year" or "I feel like the artery in my neck is numb." Mostly it was the WTF presentations that caused me a lot of pause right out of residency but I just accept as part of the job now.

Very much this.

Residency prepared me for people actively crumping, the rest of it is where things can get unclear.

That said, every year we have a newly minted EM attending or intern posting the exact same thread you have with the same concerns.

 

[gruemd]

Yeah totally normal. Now about 2 years out, looking back the biggest hurdle is learning the new systems wherever you're going - new consultants, EMR, partners/coworkers, random inexplicable hospital practices. If your residency is solid then you're almost certainly more solid at taking care of real pathology than you realize. For everything else, there's WikEM and uptodate.

 

[HemorrhagicShock]

Also know that your director and/or the rest of the docs at that site do not expect you to be fast or hyper-productive. They too want you to be safe and careful. They know it sometimes takes 6 months to a year to become familiar with the system and players (consultants/ancillary staff/whoever).

The fact that you're anxious about making a mistake is exactly what you should be feeling, which is why nobody here who has made the same transition is worried about you. You have the right mindset, and it looks like the right training, so stay the course and know that you are actually never alone. There is always somebody you can ask - another attending that's on, an experienced battle axe RN, an on-call consultant, or another ER doc at a receiving facility.

You are NEVER alone, remember that.

 

[hoot504]

You are NEVER alone, remember that.

Unless you are, which is why you shouldn’t do solo coverage straight out of residency.

I had the same attending jitters as the OP, but they went away after a month or two. A big reason for that was working at shops with tons of coverage. I’m five years out and still get nervous going into my solo coverage side gig shifts.

 

[RuralEDDoc]

Unless you are, which is why you shouldn’t do solo coverage straight out of residency.

+1
You can be very alone in an unsupportive or single coverage ED. Like a pitcher on the mound, all eyes on you, half the people routing for you, the other half routing against.

 

[TooMuchResearch]

If in doubt, phone a friend.
You should have a colleague or someone somewhere who will pick up a phone and help.

 

[Dred Pirate]

What if I happen to freeze and call for the wrong medicine or dose on a critical patient?

well - as a pharmacist I had to respond to this- this literally happens all the time - this is where you learn to work with and build relationships with all your various allied health and other specialties. Don't be true proud to admit if you don't know something of the top of your head, don't be stuborn if someone asks you for clarication on something (sometimes I am right and sometimes I am wrong because I may not have all the story)

 

[cyanide12345678]

Unless you are, which is why you shouldn’t do solo coverage straight out of residency.

I had the same attending jitters as the OP, but they went away after a month or two. A big reason for that was working at shops with tons of coverage. I’m five years out and still get nervous going into my solo coverage side gig shifts.

Eh…. It’s not the end of the world being solo coverage. Moonlighted at 4 hospitals as pgy3 as solo coverage.

First attending job was solo coverage for 2 years. Continuing to work rurally now as solo coverage. Was doing shifts at a level 3 and absolutely hated it despite all the extra support and staff.

Solo coverage isn’t that bad. You just learn to handle things even when freshly out of training. What’s the worst that can happen? You do realize that a lot of solo coverage hospitals are staffed by older FM trained docs currently. Most ER trained grads should be okay, that’s what training is for.

 

[Birdstrike]

Have a job lined up, graduating in a month. My program has put out solid graduates, but I’m feeling unprepared. As I get closer to finishing, I realize how little I know. What if I happen to freeze and call for the wrong medicine or dose on a critical patient? What if a trauma comes in and I’m solo coverage with nobody around to help? These are really frightening thoughts for me. Has anyone here felt similar?

You know more than you think. Trust in your training. 99.9% of the time, it’ll kick in and you’ll do the right thing. In instances where you’re unsure, consult someone.

Make sure A, B and C are covered, then take a breather and think.

None of us want to be perceived as uncertain or green. But if you really hit a wall, it’s 3 am single coverage and there’s no one there to curbside, would it be the worst thing in the world to call the doc on shift back at your residency, or your current ED director at home, for a 2 minute, “What would you do?”

The anticipation is always worse than the reality. Once your first shift starts, you’ll be fine.

 

[3rdJob]

You know more than you think. Trust in your training. 99.9% of the time, it’ll kick in and you’ll do the right thing. In instances where you’re unsure, consult someone.

Make sure A, B and C are covered, then take a breather and think.

None of us want to be perceived as uncertain or green. But if you really hit a wall, it’s 3 am single coverage and there’s no one there to curbside, would it be the worst thing in the world to call the doc on shift back at your residency, or your current ED director at home, for a 2 minute, “What would you do?”

The anticipation is always worse than the reality. Once your first shift starts, you’ll be fine.

Speaking as a former long-term (I got better) faculty in an EM program, we always told our graduating residents that you could call us ANYTIME at work for a question/curbside/whatever. Sometimes it just helps to bounce things off someone else to clarify one's clinical quandry .

 

[hoot504]

Solo coverage isn’t that bad. You just learn to handle things even when freshly out of training. What’s the worst that can happen?

I agree with the gist of your post cyanide, but to answer your question... airway disasters, multiple simultaneously crashing patients, extremely hairy traumas. Those are the things that make me nervous going into a solo coverage shop.

 

[cyanide12345678]

I agree with the gist of your post cyanide, but to answer your question... airway disasters, multiple simultaneously crashing patients, extremely hairy traumas. Those are the things that make me nervous going into a solo coverage shop.

You do what you can. You do your best with the resources you have. If things end badly, that’s all you could do. Death Is a natural thing, sometimes you can’t save everyone.

Airway disasters - be ready and willing to cut the neck if needed. Outside of very large centers, you probably won’t have 24/7 ENT and anesthesia in the hospital, they will be on call, but not inside the hospital usually. A very very bad airway, if your ENT surgeon is 25 minutes away or your anesthesiologist is 25 minutes away, i mean you’re still on your own essentially until some backup shows up - that’s about the same time it will take me to get a helicopter to get someone out if things are real bad.

Multiple simultaneous patients - yeah you just get used to it. If you are working at a large center with high volume and acuity, you likely will have multiple crashing patients there too - in fact, there are less instances of my having multiple crashing patients in my smaller hospitals.

Terrible trauma - give blood, fluids and fly them out. That’s all you can do. That’s not hard is it? Outcome is what it is…. I mean what else can you do.

There are plenty of times where you need specialists - having another pit doc isn’t going to help.

You do what you can do based on the resources you have - that’s all that matters.

 

[RoyBasch]

Speaking as a former long-term (I got better) faculty in an EM program, we always told our graduating residents that you could call us ANYTIME at work for a question/curbside/whatever. Sometimes it just helps to bounce things off someone else to clarify one's clinical quandry .

I'm going to take a different tack on this one.

I know this is routinely recommended to new graduates to call their old program staff for a curb side when in doubt.

But here's the thing. If after complete residency training, you are unsure about an issue, it probably is a complicated issue. There is a good chance another ER physician may not be completely confident what to do either. Furthermore, your curb-side consult to your former staff isn't really medico-legally defensible or documentable.

What do I recommend:

Call a specialist for a question. That person is actually on call for you, you can document their name, time, and recommendation in your note. It is probably a better stronger opinion anyways than a second ER physician. Furthermore--even if they are wrong--they are the specialist and considered to be the higher level decision maker who is now responsible for the issue.

If you have an EKG you aren't comfortable with, call your cardiologist on call to look at it.

If you have a question and no relevant specialist at your hospital, call the local tertiary referral center transfer line. There are always region-wide resources for particularly high liability situations such as stroke, STEMI, trauma, peds.

For example, I do some shifts at a critical access hospital with infrequent in-house neuro coverage. They have a pre-existing agreement with the regional tertiary care center with the university medical center stroke team. They have a one-call direct access to stroke neurology team through their transfer/access center. I call them directly on any stroke activation for recommendations on lytics, give/not give, transfer/not transfer, intervention/not-intervention and I document their recommendations faithfully.

Especially if you are going to be working at a small hospital with few specialists on call, you should find out what their arrangements are for stroke, STEMI, trauma, peds, etc.

I bet they already have an existing system to get support from a tertiary care center. When you are interviewing for jobs, you need to specifically ask about these things. If they do not have these arrangements, don't work at that hospital.

Otherwise, if you have a really ER specific question like how to dispo a gray-zone patient, just er on the side of caution the first year out and just admit them. If the internist/hospitalist says they don't need to be admitted, and you don't feel that strongly: Boom, there's your question answered, and you can document the recommendation made by a on-call physician for your facility.

 

[bky3c]

Immediately after residency, I took a full-time single coverage remote job (only hospital on the island), plus I did some moonlighting at critical access hospitals back on the US mainland. In hindsight it wasn't the best idea, and thinking about it now, I'm shocked that a) I did that and b) no one tried to talk me out of it... but I learned a ton that year. It's totally normal to feel overwhelmed and unprepared, but you almost certainly know more than you realize. I once got four major traumas (rural MVCs are messy) at a time in an ED with about that many rooms. Thanks to my training and some excellent nurses, the whole thing went beautifully. If you're graduating from a good EM program, you're ready.

Things that helped me:
-Memorize the stuff you won't have time to look up or ask someone about (it's not that much)
-Keep a cheat sheet in your pocket if necessary
-Learn which consultants are willing to share helpful tidbits and give you a little more in-depth knowledge when you have to call them anyway
-Learn which consultants give advice that maybe you should think twice about
-Document the cr@p out of everything involving someone else's advice -- correctly spelled first and last name, (each) time you called them, time they responded, what they said, time they arrived at bedside, etc. I've avoided lawsuits and negative consequences of patient complaints by doing this.
-Be nice to the nurses, techs, and other support staff, even when they're handing you the 10th EKG in 3 minutes. They can make your shift a lot easier or a lot harder, and they see/hear things from patients that can help you do your job better, but only if they feel comfortable speaking up about it.
-Be nice to the patients. (With the threatening/violent ones, at least keep it professional.) They'll be more willing to tell you the truth, which makes it easier to help them, and they'll be less likely to sue you. It might feel like it takes longer to listen to their whole story, and obviously you can guide them some, but if you let them get the whole story out all at once, it helps avoid having info trickle in later which necessitates extra labs, changes in meds, etc.
-Slow(er) and more conservative is the way to go when you're fresh out.

 

[Birdstrike]

@funnybanana will have a great first shift as an attending.

 

[STEMI_voy]

Reviving the thread as a new attending with a specific question: When the heck are you supposed to call ortho in the community? Like, what's the short list of diagnoses?

 

[skougess]

Reviving the thread as a new attending with a specific question: When the heck are you supposed to call ortho in the community? Like, what's the short list of diagnoses?

As long as you are calling them and admitting femur/hip fractures, you’re 95% of the way there. My orthopods do pretty much everything else as an outpatient now.

I call for unstable ankle fractures but they generally do them as an outpatient. Same with humerus fractures.

Much lower threshold to consult for peds. Basically anything that isn’t excessively straightforward/non-displaced.

 

[PianoMedic]

Reviving the thread as a new attending with a specific question: When the heck are you supposed to call ortho in the community? Like, what's the short list of diagnoses?

Call them or ask them to come in? I very rarely ask them to come in, but I’m notifying them to make sure they’re good with the follow up plan. They may want them to see one of their partners who specializes in something more than they do, and they’ll make a note of it then. Saves time getting them to the right Ortho from the beginning. It’s very specific to your local practice though. Don’t be shy about asking around, and ask when you’re talking to the Ortho if they want you to be calling them for all of the follow up requests. A lot of ours have brick walls for front desk staff so if the patient doesn’t have a referral or isn’t on their list, they won’t schedule them. We have an app that’s like slack but privacy compliant, so we can just message them the info and imaging and our plan, if they have an issue with it or want something different they’ll tell me. Otherwise I get a thumbs up emoji or some acknowledgment and we do what I planned on and the patient can get seen.

 

[wareagle726]

Only advice I would say is call some of your PEM friends and tell them how much you love them lol. I'm 3 years out now. I called my ortho bros and my sub specialty friends for the first few months. I still call my PEM friends on the reg. Tiny humans do strange things.

 

[miacomet]

Have a job lined up, graduating in a month. My program has put out solid graduates, but I’m feeling unprepared. As I get closer to finishing, I realize how little I know. What if I happen to freeze and call for the wrong medicine or dose on a critical patient? What if a trauma comes in and I’m solo coverage with nobody around to help? These are really frightening thoughts for me. Has anyone here felt similar?

Yes.
What kind of practice are you going to? If it's critical access, I have pearls.
Also, bad crap happens in EM, and sometimes that's just what happens.
You'll be fine.

 

[CoolDoc1729]

Specifically re : med dosing : try not to let this one worry you … I don’t think doses of less common meds are super important to commit to memory a) because you can just look them up b) because the nurses mostly will know the doses c) because the EMR will correct you if you’re wrong d) with drips the pump will correct the dose if it gets past the pharmacist, nurse and EMR.

Gross airways remain scary at PGY 14, it’s important to know your plan A-Z for those. Had one the other night best I could get was grade 3 view, tried glide and DL miller and settled on DL mac 3 thankfully got the tube and he never desatted or got (more) unstable. 10 years ago I would have been freaking out, would probably not have gotten it , have to bag him waiting for anesthesia or cut the neck, and would have come out dejected feeling like a dummy even though it was hard. Now I was more like.. good job cooldoc… I should let the icu doc know this airway is dicey … move on with my life

It’s important to know what backup you have and which specific staff will help. We have one badass general surgeon who will take literally anyone. Someone else’s postop sbo because they are not calling back, a trach bleed when ENT doesn’t call back, a GI bleed when GI isn’t calling back, etc.

If you’re not sure about someone, dispo, do they need a CT, more labs etc , sometimes it helps to let it percolate in the back of your mind while you’re seeing a few other patients and then circle back. You might remember a case from intern year or they might think of an actual important part of the history or they might declare that “no one ever does anything for” their supposedly new abdominal pain and stomp out of the ED and well.. that works too sometimes. Don’t be in a hurry to dispo people that you aren’t sure about, speed and confidence will come with time.

Wishing you all the best! Agree with many others that it will probably go better than you think.