Avoiding careless mistake in Internal Medicine rotation while still being efficient?

[deleted1053216]

I need guidance on how to be efficient in our IM rotation, we started about a week back.

I go in hospital before my co-intern does, I get started before him, but, my work seems to be lacking. To give you an example, we have night shift and have to sign out by 5 pm.

I am always finishing my notes later than the co-intern and end up staying later. I thought this was due to hard patients (I get called on an hourly basis about some of my pts), but hard patients can't explain everything.

A day before, I made a careless mistake, where one of my notes had carried over from yesterday in physical exam. Though things hadn't changed drastically, but, still my attending had to call and inform me.

Similarly, I had a pt, we are looking at from the perspective of an infection, which can cause anemia, pt. signs and sxs included dizziness, pt.s hgb had trended around 10.2-4. I forgot to present this as a problem to my attending the day before and the day I was off, her hgb dropped down to 9 something and my senior included anemia as a problem in his note. *** and this was the day I though had been nothing less than perfect for me.

Things have gotten to the point, I double, triple check my notes after writing them. I am also scared of presenting in front of attendings and present plans to senior before attendings, but, still mess up.

As a this year medical student, I had an extremely poor Internal Medicine rotation, with regards to their attitude towards me and in all fairness mine towards them. things had gotten to the point that I was terrified in any rotation to come, ended up failing my next rotation and almost got kicked out of medical school and had to take a few months of leave just to get life back on track with regards to step exams, recovering from that attending and such.
As a fourth year, I used to look at any wards experience, either as a thing to avoid altogether or wanted it to be quickly over with.

Every time I find myself on ward, I see myself as that third year who was the proverbial screw up.

I know there isn't a magic bullet or a medication that can fix this in an instant. This will take hardwork on my part, but, I don't want to hate wards. I want to look at it as an enjoyable experience, something where I don't want to worry each night that tomorrow I will have to face my attending. I don't want to have to worry after each mistake, they going to fail me. Is there a way to move forward in this rotation and do steps to address this?

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[BorntobeDO?]

Just keep trying. Most of us feel the same if you talk to others.

 

[thumbz]

Realizing this post in 2 weeks old, hopefully you or someone else can still benefit from this.

I think your problem right now is that you're trying to be too perfect. The first half of intern year is figuring out how to write orders, be efficient, get the work done on time and know when to ask for help. In the second half of intern year you can start to learn more medicine, but a lot of this takes place as an R2 and an R3.

And every attending is varying levels of nitpicky. My residents CONSTANTLY carry forward stale info on copy/pasted notes. If you've only been called on this once then you're already ahead. I have to badger my residents daily about carried over labs, date of dispo, exam findings, etc. Hell, I had to ask one resident two days in a row to stop documenting equal bilat ankle pulses in a patient with a BKA. A lot of stuff I let go or I'll fix myself.

If you had everything in your note your senior has in their notes you'd be a senior. Trust me, you missed the anemia that your senior caught, and I promise your attending could find at least 3 things your senior "missed" but weren't important and didn't get a mention.

Wards is hard. It's why you get 3 years of supervision before you get to be an attending. (Also, this is why NP's and PA's unsupervised on the wards terrify me)

 

[deleted480308]

If you use epic, the second you hit copy, go to the subjective and the physical and put a “***”.

 

[FutureInternist]

If you didn’t mess up, they wouldn’t have anything to teach you .

Seriously though, you seem to have self dx’ed. ie double, triple checking your notes.

I would always focus on the main issue for each patient.
CHF’er - You need to know class, I/O’s, which diuretic, echo results etc.

Sure pts have multiple issues but as an intern I would suggest getting the “why were they admitted and what are we doing for them” down cold.
The “extraneous” issues, will fall on residents and attendings to pick up on and coach you on.

Additionally, as an aside, even now, I ask 3 Qs on every pt -
1. What are they getting that they shouldn’t be (Are they still on O2 but no one did room air O2 sats?)
2. What are they not getting that they should be (Did we get PT, Speech, etc)
3. Why are they still here (medically unready?, socially unready? (Placement))

 

[Dral]

A lot of this sort of thing you'll get better at. You don't go in perfect. You make mistakes and learn from them.

Once you document 'ROS negative x10 systems' for a 6 month old, you either realize it or are told...and you remember not to do that again.

Once isn't a problem, consistently is. Just focus on the amount you know now NOT to screw up.

 

[NuttyEngDude]

You will be fine. Just keep working at it. The fact that you can recognize your mistakes puts you ahead of others.

 

[TeddyBoomBoom]

If you didn’t mess up, they wouldn’t have anything to teach you .

Seriously though, you seem to have self dx’ed. ie double, triple checking your notes.

I would always focus on the main issue for each patient.
CHF’er - You need to know class, I/O’s, which diuretic, echo results etc.

Sure pts have multiple issues but as an intern I would suggest getting the “why were they admitted and what are we doing for them” down cold.
The “extraneous” issues, will fall on residents and attendings to pick up on and coach you on.

Additionally, as an aside, even now, I ask 3 Qs on every pt -
1. What are they getting that they shouldn’t be (Are they still on O2 but no one did room air O2 sats?)
2. What are they not getting that they should be (Did we get PT, Speech, etc)
3. Why are they still here (medically unready?, socially unready? (Placement))

Nice - concur

 

[Redpancreas]

You're right that there is no magic bullet. First, appreciate that as a MS3 your attending pays you enough attention to call and makes you aware of things he would do differently whether that's coming from compassion, convenience, or nitpickiness. I did not get that until much later in my training. The fact is you had a setback and you should see it as a change in trajectory of your career. Maybe you would have gone on, but with an inattention to detail, you may have had problems in residency or a medical mistake leading to a lawsuit as an attending. Couple of points I'd like to drive home to you.

1.) Prioritize Accuracy:
It seems obvious, but introspect a little and you might find you prioritize excessive completeness by going the extra mile over accuracy. I hate to use your own examples as it takes guts to point out your own errors, but going towards your anemia example, you noted your senior added anemia. Was it necessary? I was not there, but Hb 10->9 may not be worth documenting as many chronically ill patients have baseline Hb in this range (ESRD, Cirrhotics) and then hemodilution, lab error, sepsis, among other factors can lead to changes like this. A CBC was drawn twice within 20 mins on an ICU patient because of the way the orders were released and the nurse drew both. One was 8.3 the second was 8.7. You perceiving this as a significant error makes me inclined to think you may at times prioritize excessive completeness and your accuracy/prioritization of what's important may take a hit. Tell yourself that your first priority is always accuracy. Whatever little you write should be correct. Now, if your attending gives you feedback that your notes are too scant, ask for examples of what exactly to include and build up from there.

Prioritization is essential. Without it, you will not be able to progress as an intern into a senior and ultimately into an attending. Think of prioritization as a test. Let's say there's 10 questions, each is worth 1 pt. but the last one is worth 11 pts. Before you touch those questions, you're going to tuck in that question and secure as many of those points as you can. It's the same with admissions in the hospital. Tuck in the patient's most urgent/important issue before going through your comprehensive checklist.

2.) "We are only as good as our repetitions"
The reason your senior got the anemia was likely not because they were looking carefully at the note and noticed it. They likely have a daily routine/mnemonic they follow for hospital problems. Most likely when reviewing your note he was going through his system and saw the anemia was missing. The way you get more detailed/comprehensive is not by spending more time each day writing your note (as you seem to be doing), but by repeating the same things daily until they're second nature and continue to learn new things and selectively add them to your routine. Pick the simplest order of operations for you and stick to it, only adding what's absolutely necessary as you progress. To get a bit technical, after I finish the main A&P in my admission note, I always run through systems in this order (Neuro, Cardio, Resp, Renal, Heme, ID, GI, Endo) making sure I did not miss any significant problems. In the morning, I see the patient and review/record data in my notes. This exact routine may not work for you due to your own needs or institutional expectations but you need to find routines that are effective for you or else you'll struggle.

3.) Go Line by Line:
Everyone makes small errors in their notes at first. The amount is a function of your idiosyncrasies, alertness, etc. which you can do little about outside of ensuring good sleep. After completing your note, I suggest reading it literally line by line ONCE it's completed. Avoid re-reading after every sentence or section because that wastes time. You will catch many errors this way.

Avoid Burnout:
What you describe with your life overall fits the pattern of "burn out". Again, consider yourself fortunate because it's good you've run into this when you're not set in your ways. To avoid it, find an activity that you take pleasure/solace in. Doesn't matter how lame it sounds or that it may not seem to contribute much to your life. Just do it.

You should do well!. All the best!

 

[ThatsWhatSheSaid]

You're right that there is no magic bullet. First, appreciate that as a MS3 your attending pays you enough attention to call and makes you aware of things he would do differently whether that's coming from compassion, convenience, or nitpickiness. I did not get that until much later in my training. The fact is you had a setback and you should see it as a change in trajectory of your career. Maybe you would have gone on, but with an inattention to detail, you may have had problems in residency or a medical mistake leading to a lawsuit as an attending. Couple of points I'd like to drive home to you.

1.) Prioritize Accuracy:
It seems obvious, but introspect a little and you might find you prioritize comprehensiveness or going the extra mile above accuracy. I hate to use your own examples as it takes guts to point out your own errors, but going towards your anemia example, you noted your senior added anemia. Was it necessary? I was not there, but Hb 10->9 may not be worth documenting as many chronically ill patients have baseline Hb in this range (ESRD, Cirrhotics) and then hemodilution, lab error, sepsis, among other factors can lead to changes like this. A CBC was drawn twice within 20 mins on an ICU patient because of the way the orders were released and the nurse drew both. One was 8.3 the second was 8.7. You perceiving this as a significant error makes me inclined to think you may at times prioritize comprehensiveness and your accuracy may take a hit. Tell yourself that your first priority is always accuracy. Whatever little you write should be correct. Now, if your attending gives you feedback that your notes are too scant, ask for examples of what exactly to include and build up from there. Prioritization is essential. Without it, you will not be able to progress as an intern into a senior and ultimately into an attending.

2.) "We are only as good as our repetitions"
The reason your senior got the anemia was likely not because they were looking carefully at the note and noticed it. They likely have a daily routine/mnemonic they follow for hospital problems. Most likely when reviewing your note he was going through his system and saw the anemia was missing. The way you get more detailed/comprehensive is not by spending more time each day writing your note (as you seem to be doing), but by repeating the same things daily until they're second nature and continue to learn new things and selectively add them to your routine. Pick the simplest order of operations for you and stick to it, only adding what's absolutely necessary as you progress. To get a bit technical, after I finish the main A&P in my admission note, I always run through systems in this order (Neuro, Cardio, Resp, Renal, Heme, ID, GI, Endo) making sure I did not miss any significant problems. In the morning, I see the patient and review/record data in my notes. This exact routine may not work for you due to your own needs or institutional expectations but you need to find routines that are effective for you or else you'll struggle.

3.) Go Line by Line:
Everyone makes small errors in their note at first. The amount is a function of your idiosyncrasies, alertness, etc. which you can do little about outside of ensuring good sleep. After completing your note, I suggest reading it literally line by line ONCE it's completed. Avoid re-reading every sentence or every section after you've done it because that wastes time. You will catch many errors this way.

What you describe with your life overall fits the pattern of "burn out". Again, consider yourself fortunate because it's good you've run into this when you're not set in your ways. To avoid it, find an activity that you take pleasure/solace in. Doesn't matter how lame it sounds or that it may not seem to contribute much to your life. Just do it.

You should do well!. All the best!

Great advice. Thank you