Anyone else feel incompetent and lack confidence?

[davezhan]

Hey guys! TL;DR - Small rant and whining about how incompetent and unprepared I feel everyday on the rotation.

These forums have helped me so much in the past with Step 1 preparation, so I thought I'd try again to reach out for help. I'm a 3rd year on clinical rotations, currently on internal medicine. I am slow to get things and it took me about 2 weeks to be able to get the history and physical down for both interviewing and writing notes. I felt so incompetent as my rotation is at a small town with only attendings and no residents or interns and I was expected to know how to interview patients properly and ask all the right questions and then write up my notes in under 1 hour. I know this is easy for most of you, but I came into the year as a bottom quartile student, so naturally I'm pretty bad to begin with but I am honestly trying to make an effort to catch up and learn. It is just so difficult because I didn't expect to feel incompetent and disappointed at myself every single day. Coming home, I know I should be hitting the books and studying UWorld, but I just feel drained all the time with negative emotions. One attending would always sigh disappointedly when I make stupid mistakes with my note and even yelled at me that he's getting impatient with how I'm presenting. I'm a bit scatter brain unders stress and tend to not have a systematic order. I'm honestly trying my best but I just feel disappointed everyday that my best is not enough.

That being said, in front of patients, the attendings would always say that I'm a very hardworking student and whenever I ask for feedback, they say that I'm doing okay or a good job. But I always wonder if they're just saying this to make me feel better. I always think that I'm doing a terrible job and I'm not holding myself to high standards. I just feel like I don't know anything no matter how much I try to memorize in these past 2 weeks and I feel like I am incompetent. I try not to be hard on myself but I can't seem to meet everyone else's expectations and they always seem annoyed when I ask them questions. It makes me feel bad to interrupt them when they're working all the time on real patients while I'm sitting there trying to type up a note.

After getting the H&P somewhat down these past 2 weeks, I'm now focusing on using that information to come up with diagnoses and again, I feel really incompetent. It's as if the knowledge I learned the past two years is all gone. Just the other day, a patient came in with a Colle's fracture asked me the difference between a ligament and tendon and I couldn't even explain it properly to her

It is simple stuff like this that get my attendings ticked off and they would always lecture me on these things. I've been doing my best to just listen and correct my mistakes but sometimes I can't help to make them because I just feel so stressed and scared that I'll get lectured again. Anyway, I know this is a way to learn but it's hard not to take things personally. I will still try my best everyday but this is honestly taking an emotional toll on me. The other day, I began doubting if I'd ever make a good doctor, whether I even chose the right path. I know 3rd year is supposed to be tough and I'm a soft guy but I didn't think it would be this bad. I'm fine with doing work but I hate feeling worthless all the time.

The worst part of this is not the incompetence I feel but the fact that I want to go into Internal Medicine. I've scoured the SDN boards and I read that not getting an honors basically relegates you to less competitive residencies. I really want to go to an academic IM program, but at this rate with 1/4 of the rotation over, I don't see how this can be possible.

I don't know. I just feel scared, frustrated, sad, worthless, lonely, like I don't belong here. And in the grand scheme of things, while I realize it is silly to feel this way while there are kids in Africa fighting to survive to the next day, I just can't help but feel self-absorbed. Maybe I'm just a spoiled kid who deserves to feel this way.

Anyway, I feel a little better now writing this down and getting it off my chest, but if you have suggestions as to how I can get over this and man up, then please post. I know I want to hear positive comments but constructive criticism is always appreciated as well.

Thank you for your time!

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[Psai]

Going to an academic program is easy. It's hard to get into the best programs. We all feel like this. Third year sucks. Different expectations from different attendings, you feel like you know nothing, you feel like it's the wrong path. Then you (hopefully) figure out what you want to do with the rest of your life and just coast through fourth year. I started to pick things up at the end of third year and now I think I'm doing much better with presenting.

Remember that you want to keep your audience's attention and even if the patient gave you a play by play of all the crap they had for breakfast, if it's not relevant to the complaint, the attending doesn't care. Just keep practicing as much as you can and try to take their criticisms into account. You're lucky that you aren't playing second fiddle to a resident that you just follow around but you're presenting to an attending and getting direct feedback. There were some times when the attending had no clue about my existence. Being ignored is much worse than receiving criticism. What you're describing isn't even bad, it sounds like you are being hard on yourself. You'll get more comfortable as time goes on, don't worry.

 

[davezhan]

You're absolutely right, @Psai. Thanks for your response. It helps to put things into perspective even though I also remind myself that I am extremely lucky to have attendings who actually give a damn on what I'm doing wrong even though one of them is pretty blunt about it - "I expect third years to suck so don't worry, I will expect you to suck."

At the same time, I get conflicted because some attendings tell me I need to be detailed as hell and others just want the pertinent information and tell me I get too detailed?? I guess it's a game - knowing how to please your attendings by catering to their expectations. They all tell me eventually I will develop my own style eventually when I ask them if there is a particular style to presentations or writing notes that they expect from me. Anyway, I'm going to continue to try hard. I agree with you it's better to be criticized than ignored. One of my attendings is always behind on everything so she hardly gives me any feedback or looks at my notes. During the few times we meet, she would have this spaced out look on her face when I present... I guess they only want to hear about patients with significant events that occurred overnight???

Another thing I get concerned about is reading when I'm working at the office space by the attending. I'm supposed to be studying for the shelf but I feel bad when I am studying at work when everybody else is doing work for the patients. Also, I think I'm showing my displeasure in my body language albeit unintentionally because this one attending keeps asking me "are you okay?" It's starting to make me feel nervous as hell because I'm afraid I'd get a bad evaluation from her. She also told me to go home early once because I looked like I was too tired to do anything useful at work and that I should go home to get some rest. Scared as hell that might mean a bad evaluation...

 

[Kaustikos]

You're absolutely right, @Psai. Thanks for your response. It helps to put things into perspective even though I also remind myself that I am extremely lucky to have attendings who actually give a damn on what I'm doing wrong even though one of them is pretty blunt about it - "I expect third years to suck so don't worry, I will expect you to suck."

At the same time, I get conflicted because some attendings tell me I need to be detailed as hell and others just want the pertinent information and tell me I get too detailed?? I guess it's a game - knowing how to please your attendings by catering to their expectations. They all tell me eventually I will develop my own style eventually when I ask them if there is a particular style to presentations or writing notes that they expect from me. Anyway, I'm going to continue to try hard. I agree with you it's better to be criticized than ignored. One of my attendings is always behind on everything so she hardly gives me any feedback or looks at my notes. During the few times we meet, she would have this spaced out look on her face when I present... I guess they only want to hear about patients with significant events that occurred overnight???

Another thing I get concerned about is reading when I'm working at the office space by the attending. I'm supposed to be studying for the shelf but I feel bad when I am studying at work when everybody else is doing work for the patients. Also, I think I'm showing my displeasure in my body language albeit unintentionally because this one attending keeps asking me "are you okay?" It's starting to make me feel nervous as hell because I'm afraid I'd get a bad evaluation from her. She also told me to go home early once because I looked like I was too tired to do anything useful at work and that I should go home to get some rest. Scared as hell that might mean a bad evaluation...

I'll comment on the latter paragraph first:
Be careful on how you present yourself to team members. I know it's unintentional, but it's best to nip that in the bud asap. If people think you look exhausted, you probably are.
Get up and walk around a bit. Get something to drink. Go to the bathroom and rinse your face in cold water. Take 15 minutes and watch something funny on your phone. Stretch. Anything to avoid looking tired.
If you want, ask your faculty if you can give presentations on topics. Or discuss them.
Write down questions you have and ask them.

Regarding A/P for third year: get familiar with up to date. If I ever had an issue with a diagnosis, I would have up to date and use that. They have one of the best plans for whatever CC for a student. It's easy to read.
Lastly, relax. Focus on becoming proficient at H&P and SOAP. Know how to present those two. That's the important part. Don't feel bogged down if you don't know the complete differential for patients. You're not supposed to lol. And don't lie. Never lie.

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[davezhan]

Thanks @Kaustikos . Solid advice you have there. I think my main problem right now is to come up with the entire H&P by myself with the problem list and all the A&P. At this stage in my training, I know squat about getting the differential diagnosis for complicated patients with multiple comorbidities let alone how to manage them. I end up taking forever trying to dig that information from all different sources like uptodate etc. In the end, it takes me over an hour to write the note and my attendings are clearly looking down on me for how long I take. Some tell me, "you're never going to be able to finish your work when you really practice if you don't speed up." Others just sigh. It kind of makes me sad. Today, I even found out one attending deleted my progress SOAP notes that I wrote. I mean how am I supposed to get better if this happens?? I guess I'm not too hard on myself after all. Maybe I am actually pretty terrible... yet I'm still trying... Any advice @Psai?

 

[scoKraz4]

Just keep working at it. You will get better. Im in a similar spot as you. My history is often scattered when presenting and taking me time to get it down. I just remind myself that im only a few months into all this and it isn't easy. By the time you are done with the year you will see hundreds of patients and have a much better approach to all of it. Then by the time you are an attending you will feel the same way they do about 3rd year medical students.

 

[Kaustikos]

Thanks @Kaustikos . Solid advice you have there. I think my main problem right now is to come up with the entire H&P by myself with the problem list and all the A&P. At this stage in my training, I know squat about getting the differential diagnosis for complicated patients with multiple comorbidities let alone how to manage them. I end up taking forever trying to dig that information from all different sources like uptodate etc. In the end, it takes me over an hour to write the note and my attendings are clearly looking down on me for how long I take. Some tell me, "you're never going to be able to finish your work when you really practice if you don't speed up." Others just sigh. It kind of makes me sad. Today, I even found out one attending deleted my progress SOAP notes that I wrote. I mean how am I supposed to get better if this happens?? I guess I'm not too hard on myself after all. Maybe I am actually pretty terrible... yet I'm still trying... Any advice @Psai?

A full HnP isn't easy for a third year. I struggled with the HPI and **** like that. But you just need to not let it deter you. Focus on what's normal. Once you get normal, you'll see the abnormal more clearly.
Notes don't matter on EMR because it's not taken into account. You should still practice, but if the attending wants you writing notes, use their notes as an example and write it like theirs.

You're not terrible. This is part of your training.

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[hmockingbird]

There's a large learning curve 3rd year. Everybody sucks at the beginning and that's OK. You will get better.

As far as feedback goes, try to think of specific questions, a lot of attendings/residents will respond better to this. You also might want to schedule a time to talk about things instead of asking on the spot when they might not have time to come up with something really substantial. If they don't seem to be great at giving feedback, another strategy is to find something you feel you are weak on, and tell them you are trying to work on X, could they help you out? I know it can seem like sucking up but it does help to ask to go over specific topics, so I agree with asking about doing a presentation, or even just casually going over a differential that has to do with one of your patients.

Take a post-it with the questions you want to ask into the patient room if you are allowed to, at least for a few days, then when you feel more confident, you can try to do the H&P without the help. I know tons of residents and even attending who still do this so they don't miss anything.

A lot of things that helped me with learning the ropes third year were creating routines and templates. I still use many of these fourth year as well. For presentations, practice presenting in the same order every time, that way if you get flustered, you can just think back to which section you are in (SOAP). Even if the attending want more or less detail, you can still have this basic template in your mind of how to present. For notes, similar, come up with a template (either one you create in the EMR or just in your head) of what needs to go in each note. If an attending wants something specific and extra in their notes, add it to your template so you do it every time and present it every time. In the morning, create a routine for seeing your patients, checking their vitals, etc. Do it the same way every day so that you don't forget to do something important like write down their vitals for your presentation (vitals are vital!).

As far as downtime... you are there to learn. After I finished my notes for the day, I would always ask once if there was anything they needed help with, then study. I would usually stay in the same general area so that if something came up, I could help out (like an admission), but most people know you are there to learn and you can't really do a lot of resident/attending work so there's no point in sitting there doing nothing. You could try to read up on relative topics to your patients' problems so you know more in rounds the next day.

Internal to me seems like it would've been hard to start off with because the patients' problem lists are often so long haha. For your differential/A&P, I would just focus on the chief complaint as you start out. Look up a basic differential for SOB, CP, whatever and see if any of that fit your patient. Learn the basic management/work-up of each. If you can work in the comorbidities, great. If not, at this stage of the game, IMO totally acceptable to just ask if their other disease X would play a role in their presentation. For managing their other problems while in the hospital, a lot of times it's just continue home meds and monitoring (blood sugars, vitals, what have you). Definitely include those in your problem list and note but I just think you will build up more knowledge of how to manage comorbidities over time as you practice more.

 

[davezhan]

Solid advice, @hmockingbird! I really need to come up with a schedule for doing things. I find myself easily forgetting things if I don't write it down. In fact, my attendings point out that I need to focus more. I can blame this on being anxious and on edge day in and day out but in reality, I just need to be more organized and stick to a system and write everything down onto a planner or notebook to review over the day. I'll definitely try the advice here. Any other tips people have are appreciated!

 

[deleted647155]

Cheer up! I feel incompetent and dumb all the time. I guarantee you noone went through medical training with 100% confidence.

Medical school is part acting like you know--everyone creates a facade of knowledge. But it's just a game that we have to play.

Most important is that we are all learners and we aren't perfect people!

 

[PassThePropofol]

As a former nursing student, now pre med, I faced similar issues and found that using other nurse's cheat sheets for giving report were really helpful. Do a search on these. It may be helpful to create your own as a med student. Don't know if other med students share these online.

Also it may help if you think of your patient as someone close to you. Your concern for the patient may overpower the fear that you feel.

Can you ask to see the notes of your attending as an example?

 

[star.buck]

Just stumbled on this forum... and have to say I have always had issues with feeling confidence and feeling competent... This Ted talk truly changed my life, and changed how I approach the world and how I interact with it. The change was so drastic that I applied for medical school a year before I thought I was ready, have been accepted, and am on my way to being a doctor. Take a little time to watch it... Her new book is also incredible, but takes a little more time than the 20 mins for this video.

 

[Frisho]

I think confidence will come as you do more clinical work. you got to apply the principles you learn.