Awful Clinical Skills?

[Epic_fail_2023]

Hello,

I'm a new 4th year at an east coast mid-tier MD. My preclinical grades were average-above average and step 1 went well. I also have 15+ publications and an abundance of leadership/ extracurriculars., but so far my clinical rotations have been an absolute disaster:

OB: told me i'm one of the worst they've ever seen, they had a "feedback" session with me at 3am during which they told me was that I'm bad at everything and should find a new career.

Psych: told me I'm doing great during the rotation but then, 2 months later when I got my eval, it said I barely missed failing and have awful clinical skills. Talked to the director and he said I would've gotten a better grade if I hadn't shown up at all! He said that while I'm always on time and have great people skills, I'm just bad at being a doctor

We then had an in-house step 2cs spin off exam where I got bottom of the class, despite studying pretty hard

IM, Surgery, Peds, Neuro, FM + all of my electives gave me above average to outstanding feedback. All of my shelves were high 70's/ low 80's

Of note, our clinicals are p/f so none of this is actually on my record/ mspe as I did pass in the end but at a certain point I wonder: if I'm this bad clinically, should I even bother with residency? I'd hate to fail out of that or otherwise be a terrible doctor but don't really know what to do at this point. There is no lack of effort on my part, as I've never been late, try my best to be helpful and have good people skills (as even OB/psych acknowledged this!) and I've had plenty of jobs in real life to teach me these skills but apparently I just suck at interviewing/ doing physicals I know its common to get "imposter syndrome" but this isn't that, its people actually telling me I'm bad

TLDR: Bad clinical evaluations/ uncertain about the future

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[Goro]

Sounds like you had two bad rotations.

It may be that your knowledge base for those was fine, but the actual "doing" and applying that knowledge was lacking.

You may also have given off the vibe that you were totally uninterested in those two fields, which does tend to piss preceptors off.

Focus on the good rotations...you're clearly doing something right!

 

[operaman]

Hello,

I'm a new 4th year at an east coast mid-tier MD. My preclinical grades were average-above average and step 1 went well. I also have 15+ publications and an abundance of leadership/ extracurriculars., but so far my clinical rotations have been an absolute disaster:

OB: told me i'm one of the worst they've ever seen, they had a "feedback" session with me at 3am during which they told me was that I'm bad at everything and should find a new career.

Psych: told me I'm doing great during the rotation but then, 2 months later when I got my eval, it said I barely missed failing and have awful clinical skills. Talked to the director and he said I would've gotten a better grade if I hadn't shown up at all! He said that while I'm always on time and have great people skills, I'm just bad at being a doctor

We then had an in-house step 2cs spin off exam where I got bottom of the class, despite studying pretty hard

IM, Surgery, Peds, Neuro, FM + all of my electives gave me above average to outstanding feedback. All of my shelves were high 70's/ low 80's

Of note, our clinicals are p/f so none of this is actually on my record/ mspe as I did pass in the end but at a certain point I wonder: if I'm this bad clinically, should I even bother with residency? I'd hate to fail out of that or otherwise be a terrible doctor but don't really know what to do at this point. There is no lack of effort on my part, as I've never been late, try my best to be helpful and have good people skills (as even OB/psych acknowledged this!) and I've had plenty of jobs in real life to teach me these skills but apparently I just suck at interviewing/ doing physicals I know its common to get "imposter syndrome" but this isn't that, its people actually telling me I'm bad

TLDR: Bad clinical evaluations/ uncertain about the future

Not sure what to make of this honestly. A 3am feedback session is such a terrible idea that it makes me question the OB preceptors’ judgement.

Did they give you any more specific feedback than you’re just bad at being a doctor? Like did they specifically say you take an incomplete history and miss major details beyond what most students at your level do? Did they say your physical exam skills are woefully lacking and that you often forget to perform key parts? Was it data gathering and synthesis? Telling someone they’re bad and need a new career is a really big deal, and anyone saying it better be prepared to back it up with specifics. Maybe you were just phoning it in and didn’t give a flip about those rotations, but I suspect if that were the case you wouldn’t have posted here. Most people know when they’re phoning it in and accept when their evaluators noticed.

If this were me, I would approach someone in the dean’s office that you trust. Schedule a meeting and you can go into all the gory detail about what you were told and see what advice they have. Maybe they can help gather more specific data so you have some feedback that’s actually useful.

The good news is you’re passing and you apparently did well on your other clerkships. I think you’re wise for taking this feedback to heart and digging deeper. Very often trainees will get lots of good average feedback and it’s only when they encounter someone who really takes time to notice what they’re doing that they start hearing negative things. I don’t know if that’s the case here - usually IM and surgery have enough people watching you that they’d spot terrible clinical skills but you never know.

I would definitely pursue this further and maybe your admin has suggestions of who to talk with. At my school they would have paired you up with one of the old seasoned top teaching attendings and had them put you through the paces for a few days to see what you can do, and then maybe they could give you the kind of feedback that actually help you improve.

 

[Med Ed]

OB is generally the rotation where all hope and light goes to self-terminate. Don't read too much into it.

 

[deleted1139416]

I've had rotations where I was told I was one of the best medical students on their site. I've also had an IM rotation where the resident told me that I am terrible and will fail as a doctor. Rather than relying on other people to build you up, and getting knocked down when other people crap on you, learn to trust yourself and have the self confidence to filter out criticism that is personal vs. constructive.

 

[aldol16]

In my experience, OB people tend to be pretty bipolar in terms of their feedback. Experienced this at multiple institutions. Very much sorority vibes. I wouldn't take it seriously. If there is specific feedback that you can take action on, that's a different story. If there is, you should work on those things. For example, if they're telling you that you need to be nicer to patients while talking to them. That's something actionable that you can do. Or that you need to practice suturing.

 

[Angus Avagadro]

Do you like clinical medicine? These are all skills that can be improved. There are areas that don't require as much clinically, like Path, Rads, Psych and others. While teaching students to intubate the mannequin, I had a lady insert the laryngoscope, backwards, ( the tip was pointing up and in the soft palate, not behind the tongue advancing toward the larynx). I stood in amazement as I didn't think that was possible. She looked at me sheepishly and said she wasn't good with her hands. I asked if she had considered Psych. Her face lit up and she said she had. I told her to follow her heart. 2 poor experiences doesn't mean you are bad clinically. Ask for more direct feedback and work on those areas. It is also OK if clinical medicine is not your biggest interest. However you decide to deal with these issues, I'm sure you will be fine. You have no failures or red flags so far, so you are doing pretty good. Good luck and best wishes!

 

[ChordaEpiphany]

I've had rotations where I was told I was one of the best medical students on their site. I've also had an IM rotation where the resident told me that I am terrible and will fail as a doctor. Rather than relying on other people to build you up, and getting knocked down when other people crap on you, learn to trust yourself and have the self confidence to filter out criticism that is personal vs. constructive.

This is exactly what's going on. Anyone who thinks they can judge your trajectory as a physician based on the limited interactions they have with you during M3 has bricks for brains. No one knows how good an M3 is supposed to be. Not even residents remember what M3s should know vs. what you pick up during internship. Your knowledge base and skills are largely a function of your previous rotations/training, not your raw talent.

What residents and attendings should be looking for is the rate of improvement, but that's a big ask. The bare minimum, however, is that before sitting someone down and telling them to find a new career, they should probe for a reason for underperformance. When someone is sufficiently stretched, everything breaks down. Sometimes the student who is stuttering through a patient presentation is doing so not because they're garbage at patient rapport and history taking but because they spent most of the morning pre-round learning a new EMR and looking up the format for a formal presentation because their previous rotations didn't utilize them. That student is juggling so much more in their head than the student who just got off a core rotation at the same hospital.

I'm on my 2nd rotation and I'm having this exact experience. I'm a returning MD/PhD student, so my step 1 knowledge and clinical training is a distant memory. My first rotation was extremely chill with no formal presentations, and I was basically judged exclusively on history taking and patient rapport. We did basically no assessment/plan. We didn't write formal notes. I was great with patients and mastered taking a good, thorough history. I crushed the rotation with near perfect evals, a 94 on the shelf, and a perfect score on the oral/standardized patient exam. My second rotation is in a much more traditional medical specialty. We have minimal patient interaction, and we're judged exclusively on quality of presentations, assessment/plan, and notes. My current attending is an absolute piece of work, and I'm pretty sure if she cared enough to give me feedback, she'd tell me I'll be a garbage physician.

I'm not going to be a garbage physician. I'm just a person who hasn't had a real clinical rotation yet, so I started this one with some struggle. You're not going to be a garbage physician either. You're just a person who was probably underprepared for OB/Gyn and psych (or just had awful preceptors). If you ever start doubting yourself, remember that you've got another 4 years at minimum before your practicing on your own, and there are plenty of NPs out there binging Netflix between online classes set to graduate in a single year.

 

[Epic_fail_2023]

Thank you all for your help! I definitely tried my best/ was enthusiastic on both rotations. Fo OB, our site director was out and some random third-string attending was presiding over me. He pimped me on some crazy stuff that not even my fiends going into OB knew, then said my knowledge was inadequate. Didn't help that most other in my cohort were going into surgery/OB so I was naturally bad by comparison. They actually told me I was too nice and should be more blunt and forceful with the patients. The one good piece of advice I got was to learn how to present patients, so that I did.

But this OB was nearly 12 months ago, psych (more recent) told me they expected better from someone almost a 4th year, and that my technical interviewing skills suck. Problem is- I don't see how doing well in other rotations would make me better at that- being such an oddly specific skillset, not really used in any other field.

I actually reached out to the dean of the school (have a good relationship with him since i'm on student council) and he said this all is likely just bad luck but somehow i'm still unsettled

I thought I really liked clinical medicine but dealing with **** like this is not fun at all and sucks the joy out of me, seeing how bad I've done makes me think I will fail residency, where surely the expectations are much higher. I know most people struggle with the first 2 years of medical school and suddenly kill it on third year rotations, I've been exactly the opposite. Is there any hope for someone like this to pass residency, or is it just a continuation of seemingly arbitrary bs and summary failures?

 

[Billiam95]

OB: told me i'm one of the worst they've ever seen, they had a "feedback" session with me at 3am during which they told me was that I'm bad at everything and should find a new career.

Sounds like a slow L&D night...if your L&D experience was anything like mine, you weren't given enough responsibility (or time on the service) for the OB to give you that kind of feedback.

But this OB was nearly 12 months ago, psych (more recent) told me they expected better from someone almost a 4th year, and that my technical interviewing skills suck.

Psych interviews are so unique unto themselves that, if all your other feedback was positive, I wouldn't worry too much about it (especially if you're not applying psych). On my inpatient psych rotation, my attending told me that I wasn't curious enough and that I needed to put on my 'inquisitive hat' - since I'm applying GS, I took it to be a complement.

 

[Epic_fail_2023]

Sounds like a slow L&D night...if your L&D experience was anything like mine, you weren't given enough responsibility (or time on the service) for the OB to give you that kind of feedback

So actaully it was supposed to end at midnight, but crazy life-threatening emergencies happened, keeping me later (mother and baby almost died). Ofc he decides that right after would be a great time for my feedback and so I get home at 4am and need to be back at 10am for didactics, not a fun time...

 

[ChordaEpiphany]

The one good piece of advice I got was to learn how to present patients, so that I did.

But this OB was nearly 12 months ago, psych (more recent) told me they expected better from someone almost a 4th year, and that my technical interviewing skills suck. Problem is- I don't see how doing well in other rotations would make me better at that- being such an oddly specific skillset, not really used in any other field.

One thing about toxic rotations is that you still learn something from them. You have P/F clinical rotations and that's a blessing. I'm on a toxic rotation right now, but I learned that I genuinely needed to present patients better and to learn to write much better succinct, formal progress notes.

The other thing about toxic rotations is that sometimes you can't win, even if you do everything right. My current attending absolutely sucks. She provides no feedback except that I'm doing everything wrong. I swear she even makes stuff up just so that I'm more wrong.

Patient is a 1 yo with tonsils so large they are touching each other. Nursing commenting on how huge they are. Has a temp of 100.1 and mother reports behavior changes. There is mild inspiratory stridor. I called it viral URI and say I've considered bacterial URI and allergy but those are unlikely, make sure patient can drink fluids and send home. Attending says, "You're wrong. That patient isn't sick at all. Just has large tonsils."

Patient is a 2 yo with temp of 102. So tired she falls asleep while I'm examining her. Mother says she's had white/green discharge in the mouth, but kid is so uncooperative on oral exam that neither me or nursing could visualize the tonsils. Ear exam also shows hella cerumen impaction and she's a recent non-English speaking immigrant with no PCP. Surprised this girl can even hear correctly. I say bacterial vs. viral URI, perform rapid strep test, and I'm happy to make a call and try to get them a PCP appointment. Attending performs no physical exam when she sees the patient herself and then says, "This patient has a viral URI. Ordering a strep test is unnecessary. We're an ED not a scheduling service."

During presentations if I use a single word incorrectly she immediately jumps on it and insults me. I have to magically know when she is okay with me bothering her to present a patient or she will scowl at me or simply walk away without acknowledgement. She refuses to sign necessary paperwork for the rotation. Point of that rant... some people just suck. They're bad doctors and miserable humans. Don't let their feedback bother you.

Also, psych is nothing like the rest of medicine and is basically a standalone rotation. You don't get the volume in med school to become competent in even the interview. You might learn from a rocky interview with a depressed patient who won't open up, but your next interview will be with someone manic with pressured speech or someone psychotic with disorganized thoughts. Idk how many of each of these I'd have to do to master the skill, but it's way more than you get on a medical school rotation. If you're not going into psych, brush it off. Sounds like you're doing just fine.

 

[Angus Avagadro]

When my kids had Strep, our Pediatrician told us that anytime a toddler intentionally lies down in the exam room, they have Strep until proven otherwise. Sounds like the attending regrets her specialty choice.

 

[LunaOri]

The most important factor to evaluate in a third-year student is teachability. Everything else will be learned eventually. Do your best to be open and learn, and you will be fine. You are only at the beginning, you can't be expected to know everything yet.

 

[ChordaEpiphany]

The most important factor to evaluate in a third-year student is teachability. Everything else will be learned eventually. Do your best to be open and learn, and you will be fine. You are only at the beginning, you can't be expected to know everything yet.

I wish most attendings thought like this, but most will judge you on raw ability the single time they observe you. You likely can't change this. I think a good middle-ground would be 6 months of P/F rotations so at least you're not grading based on the absolute start of the learning curve, which will be wildly variable depending on the student's previous rotations/experiences. Compress M1/M2 into 1.5 years, have 0.5 years of P/F rotations in med/surg/peds/FM, then do M3 as usual.

 

[mistafab]

You'll be judged mostly on availability, affability, ability. In that order.

Being on time and being pleasant is more important than anything else. Stay teachable and keep moving forward. Residency is more about being teachable/coachable than being skilled. That is why we use the apprenticeship model.

Lastly, don't internalize your negative feelings about psych. You suck at psych. So what. Every doctor does - that's why it is a specialty.

 

[annoyedpsychiatrist]

The feedback given to you seems very harsh and not constructive at all. This is the feedback id give to a medical student who was chronically late, rude, and disinterested. Even students ive worked with who werent great ive never said stuff like that, and im a psych preceptor. Specific examples would be useful, if there were certain interactions that were specifically bad? Interview skills are important in all areas of medicine, but take years to become skilled at. Nearly all med students suck at interviewing. Its a learned skill.

On the one hand medical students can be questionable at times, but also preceptors can be the previous questionable med student, so yeah.

When i was in med school, the clinical skills director told me i had weak clinical knowledge and that I would struggle. I then went on to score in the 88th percentile on step 2, and top 20 of my class. Passed the clinical skills exam with ease. So yeah, sometimes people have no idea what they're talking about.

 

[Splenda88]

Medical school sucks.

I don't think you should beat yourself up because of these eval. OB is known to be a malignant rotation in most places. ?Physical exam in psych!

My main issue w/ med school rotation is that the people that talk a lot are the ones who usually get good grades even if they don't know what they are talking most of the time. That thing became obvious to me when I was a senior resident with med students on my team.

 

[Lawpy]

When my kids had Strep, our Pediatrician told us that anytime a toddler intentionally lies down in the exam room, they have Strep until proven otherwise. Sounds like the attending regrets her specialty choice.

That attending shouldn’t be teaching (and should be kicked out by the school). It’s garbage attendings like her who make 3rd year a miserable experience for students

 

[deleted1095841]

The conventional wisdom is to learn from every experience, but sometimes, there is nothing to learn. Just ignore them and move on. It's up to you to decide if you want to be a clinician or not.

 

[MateoGM416]

I don't think you should beat yourself up because of these eval. OB is known to be a malignant rotation in most places. ?Physical exam in psych!

Why is OB considered a universally malignant rotation everywhere?

 

[Splenda88]

Why is OB considered a universally malignant rotation everywhere?

I am not sure why to be honest... There is an hypothesis out there but there is no validity to it. If that was the case, peds would have also been malignant.