Anyone else feel totally incompetent?

[chagall]

I'm starting to feel more and more so. I'm close to finishing up 3rd year, so I still have another year left in my mind to feel like I can be OK with getting an MD, but I'm worried that may not be enough. I did well on Step 1 and had good grades coming in, but this rotation especially has made me feel like I may not make a competent doctor.

I'm fine with taking a history, but the physical is another story...I always seem to miss something, and I'm not good at some of the basics. I often can barely hear any heart sounds, much less a murmur, and my fingers creaking often sound louder than anything else (although I'm holding the stethoscope like I'm supposed to and trying to be still).

And worst to me, I can't often seem to put it all together to come up with a differential and the most likely Dx. On the floor, with time to research and think more, I managed better, but now on outpatient, it's become more obvious since I have to do it so fast. My mind for some reason seems to blank out on me pretty often.

This is mostly my fault, I'm sure...I have been depressed and probably lazy for several years, and I have skipped out on some lectures and studying when not totally required. I don't know why exactly.

Now I'm regretting it, and I don't know what to do, or if even more studying would help this situation. I'm not yet sure which specialty I want to go into, and I did feel more competent in one or two other fields I'm considering, but now I'm finding I like internal medicine too. But believe me, I am too much of a responsible person at heart to let myself be an incompetent doctor.

I also don't know how much of this is my attending now...she is pretty critical, and I could count the nice comments she's made to me over the month on one hand.

Well, at least I vented...anyone have any ideas?

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[Psychoanalyzed]

I don't necessarily have any ideas.. but I can sympathize. I am feeling pretty useless myself.. I am still undergrad and I have always known I wanted to go Med school but only in my last year did I try to cram in volunteering, research, clinicals.... My grades went downhill.. unredeemable GPA so now I need a post bacc and I am too lazy to study for the MCATS so I am taking the GRE's first.. which I did today.. and actually did well on.. but still.. it doesn't redeem 4 years of wastefulness.... I think you will be fine.. (like a friend always says), you have come this far.. keep working at it!!!

 

[Entei]

I'm starting to feel more and more so. I'm close to finishing up 3rd year, so I still have another year left in my mind to feel like I can be OK with getting an MD, but I'm worried that may not be enough. I did well on Step 1 and had good grades coming in, but this rotation especially has made me feel like I may not make a competent doctor.

I'm fine with taking a history, but the physical is another story...I always seem to miss something, and I'm not good at some of the basics. I often can barely hear any heart sounds, much less a murmur, and my fingers creaking often sound louder than anything else (although I'm holding the stethoscope like I'm supposed to and trying to be still).

And worst to me, I can't often seem to put it all together to come up with a differential and the most likely Dx. On the floor, with time to research and think more, I managed better, but now on outpatient, it's become more obvious since I have to do it so fast. My mind for some reason seems to blank out on me pretty often.

This is mostly my fault, I'm sure...I have been depressed and probably lazy for several years, and I have skipped out on some lectures and studying when not totally required. I don't know why exactly.

Now I'm regretting it, and I don't know what to do, or if even more studying would help this situation. I'm not yet sure which specialty I want to go into, and I did feel more competent in one or two other fields I'm considering, but now I'm finding I like internal medicine too. But believe me, I am too much of a responsible person at heart to let myself be an incompetent doctor.

I also don't know how much of this is my attending now...she is pretty critical, and I could count the nice comments she's made to me over the month on one hand.

Well, at least I vented...anyone have any ideas?

The way you're feeling is completely normal. I'm a 4th year student, and I'll swallow my pride and admit that I still feel really stupid when it comes to a lot of things. You're not expected to know everything just because you finished med school. THIS IS WHAT RESIDENCY IS FOR. An IM residency takes three years for a reason. The two years you spend on clinical work in med school is a drop in the bucket compared to what you will learn in residency. It takes experience to feel comfortable with these things, and there's no way to rush experience.

 

[DebDynamite]

You're not expected to know everything just because you finished med school. THIS IS WHAT RESIDENCY IS FOR. An IM residency takes three years for a reason. The two years you spend on clinical work in med school is a drop in the bucket compared to what you will learn in residency. It takes experience to feel comfortable with these things, and there's no way to rush experience.

Ditto the above post. I'd like to point out that your awareness of all that you don't know will in fact make you a great doc some day. If you didn't feel unsure at this point in your training (even if you were getting the diagnosis lots of the time) you would be reckless and too "full" to teach. Don't let a critical attending chip away at your sense of self worth- remember that your knowledge and skills will come in time.

 

[medgirl20]

Just some tips on the feeling useless.

Practice the exam on everyone you can you need to hear hundreds of normal heart sounds to be comfortable with them.

Being if you hear a murmor don't jump in and say its aortic stenosis go through it systematically I hear a murmor it's louder on etc.

Be systematic always do it the right way I know it can be time consuming and frustrating when you see drs randomly doing bits of exams. I think of it like your driving test you never drive as perfectly as you did that day in real life.
The same can be applied to all aspects of the exam.

For the differential I find it usefull to sit down with a scrap of paper and write out all the ddx you can think of for a topic eg chest pain then beside each ddx write the other fx you would be looking for.

When you see a patient read about them it's time consuming but it helps if you remember pancreatitis as Mr X, rather than just learning the disease.

Finally study the common things about the common diseases first, then common things about uncommon diseases and then uncommon things about common diseases... you never get to uncommon things about uncommon diseases and these are rarely tested anyway.

 

[babyruth]

Agree with above, go back to basics and be thorough. There are also pocket books and programs that list common differentials based on symptoms (i.e. diagnosasauris, epocrates complete, etc). You might try looking into these so if you can't think of a differential for SOB, you can look it up quickly.

 

[filter07]

Always think. Treat the hx/pe has more than just a formality. That will help you not miss things.

For outpatient clinics, whenever I was stuck I used my PDA to remind myself of differentials, specific physical exam findings, and things like that. You can always sneak in a minute or two of PDA review before you present your patient. Sometimes I did this in the hallway.

 

[Critical Mass]

The way you're feeling is completely normal. I'm a 4th year student, and I'll swallow my pride and admit that I still feel really stupid when it comes to a lot of things. You're not expected to know everything just because you finished med school.

I'm not disagreeing with you, but why does it need to be this way? Why don't they start with clinical basics and then build on them with more advanced studies like they do in other health care professions? Seriously, does anybody actually remember their M1/2 content after USMLE I?

 

[mrdowntoearth]

You know, I always wonder about this as well. As 3rd years, our ability to formulate ddx and management plans is limited to a great extent by the lack of clinical experience. There's no way the assessment and plan in our H&P notes would be as high quality as residents'/attendings'. There's no way my physical diagnosis skills will be at the same level as attendings. It's all about experience and I realize that this is beyond my ability. That said, you will always be perceived as "incompetent" by attendings, and this definitely affects how they would evaluate you or write you LOR. So, I always wonder for those people out there who got excellent LORs/ great evaluations, how good are their PD skills/ SOAP notes?

 

[loveumms]

Everyone feels like this at some point (those who say they don't are lying).

I can remember the end of third year - I wanted to kill myself. I hated peds and OB/GYN and was so miserable that I thought about dropping out at least once a week. It was the enormous debt that prevented me from doing so.

I wouldn't count on fourth year making you so much smarter though b/c it is pretty much a vacation (or at least for me). Take your step II's as early as possible ... believe me it just gets harder the longer you wait. But, know that once you hit intern year you will pick up so much knowledge. The learning curve is huge and you will be competent. It's human nature to try and do as little work as possible to get by. Of course there will be the gunners who study every second of every day - and hey may know more then you but, they too are probably miserable and feel inadequate ... that is human nature too.

So, keep your head up and realize that you are in med school for a reason - you deserve to be!

 

[Anka]

Just go with the flow; you'll get better at what you do. Meanwhile, just subtract out all the belittling tone people are using, and get the data you can out of it. And take none of it to heart.

Anka

 

[Medpilot]

Sounds exactly like my life now at the end of 3rd year. We'll be fine. Everyone has their niche. As for all of the stuff we don't know, a friend used to say... Medical school is like trying to take a drink of knowledge from a fire hydrant with a dixie cup.

 

[ericdamiansean]

I'm in my final lap, about 6 months to go before I graduate as a MD and here's what I think.

Forget about your consultants and residents who tell you that "When I was a medical student, I knew this, I had this memorized and that bla bla bla.." They were exactly at where you are now, perhaps even worse, and do not be surprised, some of the most knowledgable and respectable doctors today, may have not been the best of medical students.

50 years ago, before the boom of medicolegal issues and before people knew more about their rights, how do you think surgeons perfected their skills when they were junior surgeons? Trial and error, and with that, you get a few deaths here and there which of course could have been prevented today easily. People will make mistakes, everyone goes through this phase and it is part of learning as a doctor and as a human being.

You have to have decent brains to have the foundation for you to practice, formulate a diagnosis, investigate and manage, but the rest will come with time, as the other posters have said, that's what residency is for.

Of course, the really bad med students, if the exams do not screen them out and they manage to squeeze through med school, they might be up to some no good as we speak.

Medical schools want to produce doctors who are SAFE, that's all. You may not score on your results, but if you know what to do if someone comes in with an MI or DKA, set a line, manage him properly, you're OK, and most likely, you'll pass through med school and be a fairly good doctor. Anything after that, it's up to you. But if you can't, then, you're in trouble.

Another example: Let's just say that you may have perfect board exam scores, you CAN diagnose someone with hypovolemic shock, but if you can't set up a drip to resuscitate him (perhaps due to all the time spent studying and not on practical procedures), I think that makes you more 'dangerous' to practice than someone who just had an average pass.

So, don't worry too much, learn as you go along.

 

[leorl]

don't worry. doesn't matter how smart you are, medical school...and the cynical nature of medical profession itself, will provide you with a lovely lifelong asswhipping and a great lesson in humility. I'm 5 weeks from my final exams (okay, IMG but the sentiment is the same everywhere), where you'd think we should know stuff by now...and we do...but every day is a lesson in how much you don't know. And everyone says or does something that appears utterly stupid at somepoint on a daily, if not weekly basis.

Coming up with Ix and DDx are tricky...you always miss something. Get one of those Differential Diagnoses books. They can be quite helpful. I think there's one out published by Churchill & Livingstone. Ok, so it might have brit spellings and all, but the ideas should be the same. It also helps to have a very systematic approach - (ie. "What Ix would you do?" your answer: "well, I'd break my investigations into a hematological, biochemical and radiological approach... in my hematological investigations, i would include and FBC with differential to look for abnormalities in hemoglobin or signs of infection (with the WCC), etc etc etc... U&E for monitoring of renal function and measuring hydration status, etc. ) but if you break down your approach instead of trying to think of everything all at once, then it can really help ease the mental anguish.

do as others above have said...systematically from the most common to least common. So say for ...dyspnea, start from your head and go to feet - break it down into...infectious causes, then cardiac causes, parenchymal lung causes, then GI/GU causes, down to malignancy, "Pain" hyperventilation / trauma, etc.

 

[Gem134]

I struggle every day with wanting to drop out. It was better on surgery, and I have had brief moments of thinking something was pretty cool. But overall, I have not enjoyed third year very much - and I am not sure if it is the year, or medicine in general.

Anyway, what I have done is this. When someone is constantly criticising what I do/say then I try very hard to listen for what I can learn from them. Are they saying 'do it this way' but just not saying it very well? Even the worst ass**** can still teach me something. And I also make sure that I am assertive and go back to them and say "Dr so-an-so, am I doing it better now? what should/could I be doing differently to be better?" or whatever. Sometimes just being assertive with a difficult person can make them stop being so harsh. Some people are critical but really just want us to work harder/be better/smarter or whatever.

I also read like there is no tomorrow. I am still waiting for someone to sit down and explain things to me. Ain't going to happen. Now, I assume no one will teach me anything and I am there all alone. So I use lots of pocket books like http://www.amazon.com/Differential-...4084926?ie=UTF8&s=books&qid=1173375378&sr=1-2, and surgical recall, or SOAP notes books, or pocket Harrison's, Washington Manual or anything that you can quickly thumb through and get the background on everything you see. Pretty quickly, you get ok at knowing the material because you have worn your books down to a nubbin. Same for physical diagnosis, I take my time and really work through the heart sounds, where they are located and all that. Bates and Schwartz are excellent for making sure you really are getting the techniques down. If I can't hear a murmur [feel a lump], then I say "I can't hear this murmur [feel the lump], can you show me where it is?"

I was a slow learner, but I also have felt the same way. I hope medicine begins to feel better for me too, but at least now I feel like I do better because of these methods I describe. Most of all, I try and be teach-able, and I go back and ask people questions, and for feedback. It's a weird process. Hang in there!

 

[CaptKirk]

I hate third year. That's it.

 

[chintu]

I second what everyone else said. There's a reason why so many med students hate third year. You are constantly thrown into new situations w/o any prior experience in dealing with that particular pt population and at this stage you are barely capable of getting a good history, much less a physical and a differential dx. And instead of taking the time to teach you how to get good at it a lot of residets/attendings just ask you random factual questions about that specialty that you have not learned and try to make you feel stupid. I think pimping is a great way to learn but I also think there's a way of going about it without antagonizing a student who isn't supposed to know something. It is a power trip where they take out their anger/frustrations on a lowly student, as if there's isn't much going on in our heads already. I have learned most from attendings and residents who keep their cool and are tolerable to my mistakes and then take the time to go through the basics. This is true of everyone from family docs to surgeons and I have surprisingly come across many surgeons who are great teachers as well. When you only spend a couple of weeks on a service and you are barely starting to learn something it is time to move on and repeat the cycle. So it is very normal to constantly feel idiotic in third year at whatever stage you are. I can't say that I am all that much better at anything at this stage then I was at the beginning simply because there hasn't been many opportunities for reinforcements. I surely have learned many random facts about certain specialties which are not going to be of any use to me anyway unless I go into that specialty. I guess the point I am trying to make is its okay to feel like this even at the end of third year or fourth year for that matter. When we hit intern year and are thrown into responsibilities we will pick it up like we have never before and start building up the knowledge and experience as that is what we'll be doing the rest of our lives.

 

[QuinnB]

I agree with a lot of what was said above. The thing about 3rd year for me is that I'm at the end of it right now (last rotation) and I am just burned out. It sucks to think that I'll get a few days off and then have to start the ridiculously over the top subIs I have coming up...there is a lot of emotional/physical abuse this year that I really wasn't expecting. Everyone talks about pimping, scutwork, etc...but I am friggin drained.

 

[wrested]

I'm in my final lap, about 6 months to go before I graduate as a MD . . .

You graduate in September? How does that work with starting residency?

 

[ericdamiansean]

You graduate in September? How does that work with starting residency?

Not based in US

 

[tr]

I just want to stick my two cents in here.

So you know where I'm coming from, I'm an MD-PhD student who is just about to finish up. The class I started with are now PGY-3s, and I've had the pleasure of working with several of them (who matched at our home institution) over the past year.

The difference between these people when I last interacted with them a few years ago and now is amazing. Just amazing. I remembered them all as ****-up med students, desperately cramming stuff for Step I, complaining about their 3rd-year schedules, etc, etc, etc. I even remember thinking at the time, "wait... these yo-yos are the future of health care in the US?.... Uh-oh!"

And now they are all amazing, highly competent, knowledgeable, professional physicians. Seriously, I was completely floored. I would feel privileged and completely comfortable being a patient of any one of them.
(Of course I'm myself still a ****-up med student - albeit a slightly aged one with a useless PhD degree - which is no fun at all; but that's a complaint for a different time.)

So the bottom line is, I wouldn't worry about it. Residency appears to be a crucible that, by some strange alchemy, takes your typical base-metal med school fools and turns them into gold. Really. I'm sure you'll do fine. The fact that you're worried about it at all is probably an excellent sign.

 

[wrested]

Not based in US

I guessed that that was probably the case, and I suppose I should have worded my question a bit more clearly. I was speaking more from a logistic standpoint... Do you have to wait until next July to start residency (if you plan to do a US residency), or do you plan to stay where you are and system simply runs on a different calendar there?

Just curious. We now return to our regularly scheduled programming.

 

[ericdamiansean]

I guessed that that was probably the case, and I suppose I should have worded my question a bit more clearly. I was speaking more from a logistic standpoint... Do you have to wait until next July to start residency (if you plan to do a US residency), or do you plan to stay where you are and system simply runs on a different calendar there?

Just curious. We now return to our regularly scheduled programming.

So far I've only completed Step 1, whether I plan to move over to the US for my residency would depend on the couple of months after I graduate, am not sure if I would be able to cram Step 2, CS etc by next July though, most probably not.

The system where I am from (Malaysia) is different. After you get your MD, you're expected to work as a junior doctor for about a year, rotating in all major rotations ie medicine, surg, peds, obgyn. After that, you decide on what specialty you would like, hopefully get accepted into the program and go on from there. Perhaps rather similar to the Brit program.

But of course, you can always leave the country and do an immediate residency eg US, but if you decide to come back after your specialty training, you start as a specialist with specialist pay and benefits but you're bonded to the government service for 3 years before you go off to the oh-so-profitable private service. Oh, and you get to bring back 2 cars tax free (Let's just say that a 2006 Mercedes SLK costs about $60000 in the US, it would costs about $150000 with taxes here)

 

[Hard24Get]

I just want to stick my two cents in here.

So you know where I'm coming from, I'm an MD-PhD student who is just about to finish up. The class I started with are now PGY-3s, and I've had the pleasure of working with several of them (who matched at our home institution) over the past year.

The difference between these people when I last interacted with them a few years ago and now is amazing. Just amazing. I remembered them all as ****-up med students, desperately cramming stuff for Step I, complaining about their 3rd-year schedules, etc, etc, etc. I even remember thinking at the time, "wait... these yo-yos are the future of health care in the US?.... Uh-oh!"

And now they are all amazing, highly competent, knowledgeable, professional physicians. Seriously, I was completely floored. I would feel privileged and completely comfortable being a patient of any one of them.
(Of course I'm myself still a ****-up med student - albeit a slightly aged one with a useless PhD degree - which is no fun at all; but that's a complaint for a different time.)

So the bottom line is, I wouldn't worry about it. Residency appears to be a crucible that, by some strange alchemy, takes your typical base-metal med school fools and turns them into gold. Really. I'm sure you'll do fine. The fact that you're worried about it at all is probably an excellent sign.

Yeah, I am also a returning MD-PhD at a school where at least a fourth of my classmates have stayed and I ditto that sentiment.

Though I sometimes worry I'm going to be that "one" that never achieves that same level of excellency 'cause I feel old and rusty compared to my new classmates

 

[pjl]

Practical advice for your stethescope: If you are making a lot of noise on your stethescope and cant hear anything, just set the thing in the right spot and move your hand away. You can axtually hear pretty well most of the time. Not quite as fancy as the push down for the diaphram and lightly for the bell, but better than you finger noises. Once you do that for a bit start getting fancy and actually touching it. Best advice I ever got for hearing murmurs, listen for silence between the sounds, if it is noisy, there is a murmur. Sounds stupid but if I listen like that I catch more of what those fancypants-rub-a-1/6-murmur-in-your-face cardiologists hear.

For the rest, just have patience and keep working. Somewhere at some point things will start to click. You will still feel like an idiot a lot, but it will get better.

If you wanna feel good about where you are at volunteer to be a practice patient for first years learning the history and physical exam. Those guys really suck.

 

[cbass1350]

Don't be too critical of yourself. If you don't know something, try your best and read about it. I usually feel like crap when an attending asks me a question and I don't know the answer . But I will be damned if I don't go the library and read up on it .

The problem with the murmur is more based on experience than anything else. It's not a skill that you can build up overnight. Once I heard a third year IM resident mention that he actually started to be comfortable with hearing murmurs in his second year.

If a resident or attending is being critical of your work (in a constructive way), then look at it as an opportunity to improve as a future doctor instead of letting it bring you down.

best of luck