DancingFajitas

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i dont feel as if i ever have to time in clinic to come up with a solid differential and formulate a treatment plan or plan for tests before i get to the attendings....sometimes i just fly out of the room and right to them, only to realize i haven't really thought about what drugs i want to give or what dosages,etc..anyone else have this problem and if so how are you going about getting better at it?
 

Rendar5

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Don't worry, it takes time once you start clinical years. You're not used to having set formulations enter your head as soon as you hear the chief complaint. Just at this point try to get the top 2 or 3 in your differential, and you'll start learning what you can't forget to include in your DDx and workup. The more you do it, the less conscious thinking you have to do and the easier it becomes.
 
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DancingFajitas

DancingFajitas

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when did you finally get comfortable with it? intern yr or later?
 

ucsfstudents

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Don't worry, it gets better with time and experience. The more patients you see, the easier it will be to formulate a differential diagnosis.

One advice is to quickly figure out what the top 10 chief complaints are for that clinic and study those when you get home. Study DDx, workup, and treatment for those top 10.

Also, have a DDx guide around.. one i"ve found helpful is Differential Diagnosis Pocket.

Also try not to "run into" your attendings before you are ready to present. If they ask you whether you are ready or not, tell them you just need a few minutes. They want to hear the full presentation, including the assessment and plan, so if you're not ready with your full presentation, you need to ask for extra time. You will be judged by how well you present.

Appear confident during your presentations, state your top 3-5 differentials with confidence, state what you think it is most likely, and tell them your workup and treatment plans (if there is anything to treat). If it is just a f/up appt for a chronic illness, make sure you know what to ask for the history, and your plan should address any abnormal findings on history or physical exam or lab. Make sure to also mention when you want to see the patient next.

Hope this helps!
 

Rendar5

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when did you finally get comfortable with it? intern yr or later?
completely depends on the service. Some of them I felt comfortable by the end of the rotation or by my 4th year. Some of them I still don't feel comfortable (but I know enough to fake it). Regardless of comfort, I'm still an intern, and there's still a ton of refining I have to do
 
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DancingFajitas

DancingFajitas

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so as an intern, what things are you working on?
 

QofQuimica

Seriously, dude, I think you're overreacting....
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Getting "comfortable" is all relative, and every patient/new team is a learning experience. Look at it that way, and don't be too hard on yourself when you screw up. From now on, every time you struggle with any part of a presentation, ask the preceptor for advice about how to improve, and try to do what s/he tells you. The next presentation will go better if you make a concerted effort to do better. Especially when you work with the same preceptor for a while, the improvement will be clear to everyone, including you.

When I was near the end of my third year, I did a presentation that was pretty awful. It was my first day on that service, and I didn't present the A/P the way the attending wanted. Not only that, but I didn't really understand what she wanted at first. So she and the resident prompted me as I struggled through, and then I asked them to let me present the A/P again, which went much better the second time. There was also a first year student there shadowing, and I made a comment after rounds to her about how I had really screwed up that presentation. (Paradoxically, I felt much more embarrassed about the first year seeing me struggle than my team.) She looked at me, and said, "I was thinking how awesome your presentation was, and I hope I'll be able to present like that some day."

That really put things in perspective for me. We're students, and if we knew how to do everything a physician does already, we wouldn't have to go to medical school. "Everything" includes presenting patients. You'll often feel like you could have presented better, but as long as you are honestly trying to incorporate the feedback you receive, you will present better than you did the last time. As you start to improve at presenting, you'll keep setting the bar higher, which is a good thing because you'll keep improving. The important thing is to be open to the feedback you receive from your preceptors, and if you don't get it spontaneously from them, *ask* for it.

Hope this helps, and best of luck to you. :)
 

Rendar5

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so as an intern, what things are you working on?

Stream-lining and handling more presentations and workups at once, learning to refine my differential more (some zebras are important to look for, many aren't), getting overall management and dispo going in my presentation on top of ddx, including doses and selections of drugs/treatments, learning what stuff to order ahead of time and what stuff to hold off on before presenting. There's also plenty of stuff you don't learn in med school that gets added onto my plate.

I don't get to say "i think we should do a pelvic next to see if it's this". Instead I have to say "I already did the pelvic, so I've ruled out PID, I put in an order for PO Contrast and am planning on doing a CT to r/o an appy, I'm also considering IBD and will test for that pending the CT results, if everything is negative, then my plan is to discharge her."

So I not only have to get my H&P straight and think about what the workup will be like, I have to have the workup already going as I present, narrow realistic Ddx instead of showing off the rare zebras it could be, plans in place for what to do if my workup doesn't show anything, and having possibly 2-3 of those at once before presenting.

And it's not like it's a sudden change, I already started getting used to graduated responsibility and subconscious algorithm sets from my sub-I and from my 4th year electives in my current field.

EDIT: in case it wasn't clear, that whole little algorithm is what I'm striving for, I'm not there yet :)