Coping with Mistakes during residency

[Hard24Get]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

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[Pinner Doc]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

The way I see it is this: right now, you're expected to practice, and to sometimes screw up. In a few years, you'll be an attending, and you'll be expected to be perfect. You'll be glad you got your kinks out now.

(It's sort of like, now that I'm not an intern, I wish I had asked as many questions as I could have last year (when I was). Now I'm expected to know the answers.)

 

[Stitch]

I agree with the above to some degree. Now's your chance to miss things and learn whether it's a diagnosis or a procedure. If you're feeling that things aren't clicking and they should be, then maybe you should look into attending some procedure workshops or go out of your way to practice the things you're not getting.

Maybe I'm wrong, but your post sounds a little depressed. If you're really feeling that down/discouraged, then you need to find a mentor or someone to talk to. Burn out isn't uncommon during residency, and it certainly is frustrating when you feel like things aren't falling into place. I'd suggest talking things over with your PD or advisor if you have one. They may be able to point you in the right direction or give you a pick me up.

 

[Hawkeye Kid]

Great advice above...this is one of the roles of the faculty (especially the PDs) so don't be afraid to use that resource. It's also the time of year when residents start to get down. You're physically, mentally, and emotionally worn down, the days are shorter, there's holiday stress, etc. I remember being especially punchy around the end of January. Also, think about talking to your classmates--you might find that you're not the only one in your boat. Good luck and keep your chin up.

 

[uncwalley]

As one who is very much like yourself, I have been in your situation many times. You really need to step back and look at your mistakes. They seem so big in the moment. In general, they aren't really that huge and the fact that you didn't think of the perfect answer or you missed a diagnosis only a reflection that you are still training. You aren't supposed to have all the answers. When you graduate, you can't quite fall back on the comfort of somebody having your back. At that point, you have to realize that you live and work in an imperfect system where you cannot possibly be correct every time even though you are expected to be. You'll make mistakes, but humans are pretty resilient and the vast majority of patients aren't out to sue you.

 

[RxnMan]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

Talk to someone. If you're actually the worst in your class (not likely ), then your PD will get you help. If you're better than you think, then discussing things will give you perspective and boost your confidence. If you're becoming depressed, then your PD will get you help.

 

[Haemr Head]

The day that you feel that you are beyond making mistakes and know all you need to know, you should practicing because you are officially dangerous. Everyone of value in our field feels inadequate and makes mistakes. Being anxious when you start your shift is a good thing. This does not stop with residency or even after 20 years of practice.

How you deal with your errors isn't easy. An old saying was that every great physicians has a personal graveyard. You will forget most of your victories but live intimately with your mistakes. So you need to understand that this is not a sign of inadequacy but part of your continued growth as a physician. If what we did was easy, it wouldn't be worthwhile.

So here are a few things that I think help:

1. Mentors and friends with whom you can be completely honest when discussing specific cases and how you feel. They need to be people who will support you but will also provide constructive criticism. Any decent program should have a good number of these people.

2. See each error or lack of knowledge as a guide to knowledge acquisition, not a sign of worthlessness. Promise yourself that each time this happens, you will read and seek enough information to become an expert in the area that embarrassed you.

3. Make a special effort to see the sorts of patients that tripped you up the first time. Practice really does make perfect. The more patients you see, the more you will find that your confidence and speed grow and your error rate drops.

4. The attendings who's respect you care most about will prize your work ethic and honesty above your brilliance. As long as you personally know you are working hard and are striving for perfection, you are doing your job. That's all any of us can really
take pride in.

 

[gman33]

Talk to faculty members for advice on how to improve your performance.

As far as your attitude, something that has helped me in the past, is to realize any major change in your life is going to be stressful and may lead to some form of depression or anxiety (in the general non-medical sense).

I would give myself some arbitrary length of time like a year, and know that during that year I was going to screw some things up and not always feel so hot. Just keeping that idea in my back pocket helped me get through some pretty rough times.

At two points in my life, I took on new roles in my previous career, that at the time seemed well above my capabilities. The first year was pretty rough, but after that it was pretty smooth sailing. It's hard when your confidence takes a hit, and you should do whatever you can to try to maintain it. Lowering your standards, like thinking that you should never screw up basic things, is one way to help keep a good attitude.

 

[roja]

The day that you feel that you are beyond making mistakes and know all you need to know, you should practicing because you are officially dangerous. Everyone of value in our field feels inadequate and makes mistakes. Being anxious when you start your shift is a good thing. This does not stop with residency or even after 20 years of practice.

How you deal with your errors isn't easy. An old saying was that every great physicians has a personal graveyard. You will forget most of your victories but live intimately with your mistakes. So you need to understand that this is not a sign of inadequacy but part of your continued growth as a physician. If what we did was easy, it wouldn't be worthwhile.

So here are a few things that I think help:

1. Mentors and friends with whom you can be completely honest when discussing specific cases and how you feel. They need to be people who will support you but will also provide constructive criticism. Any decent program should have a good number of these people.

2. See each error or lack of knowledge as a guide to knowledge acquisition, not a sign of worthlessness. Promise yourself that each time this happens, you will read and seek enough information to become an expert in the area that embarrassed you.

3. Make a special effort to see the sorts of patients that tripped you up the first time. Practice really does make perfect. The more patients you see, the more you will find that your confidence and speed grow and your error rate drops.

4. The attendings who's respect you care most about will prize your work ethic and honesty above your brilliance. As long as you personally know you are working hard and are striving for perfection, you are doing your job. That's all any of us can really
take pride in.

If you didn't have knowledge deficits and made mistakes in residency, then you wouldn't need to do a residency! You could have walked off the graduation stage and started practicing. Obviously, that is not the case.

You have hit that part in your training where you know enough to know you don't know a lot. And most importantly, you can recognize your educational needs. I know it must feel devastating, but you absolutely should have knowledge gaps. And if you can recognize them, you can start to address them.

In essence, you are supposed to feel like there are gaps. You are supposed to have areas to be improved upon. That is absolutely the point of residency. And it will not change when you are an attending, as Haemr states. The important point is that you will always have knowledge gaps. You need to know how to recognize them and address them.


(and pssst: knowing you, you are not the last in your class. )

 

[Haemr Head]

(and pssst: knowing you, you are not the last in your class. )

(and I remember you from your interview here in Boston. If you were last in your class, it would be a far better class than any I have ever seen. Based on your concerns, I wish we had been able to recruited you! You seem to have the characteristics I look for in a resident in the early years of training - self awarness and the need to excel. Roja and her team are lucky to have you. ).

 

[Rendar5]

My first several central line attempts I couldn't get it for the life of me without major assistance from a senior or an attending. Now after screwing up a lot and making my mistakes, they're starting to get a lot easier. Same with a lot of other patient type situations I've dealt with, same with my efficiency, same with how I present patients to consults and outside attendings. The more mistakes I make, the more I'm called on them, the better I do because I can see where my mistakes lie and learn to avoid them better everytime.

 

[Hard24Get]

Thanks all very much for the votes of confidence and support. I feel much better now. I was down in the dumps because I was notified shortly after I left my shift that there had been a complication from my line and I wasn't sure if the patient was dead or alive.

Fortunately what was thought to be a ptx was just a mucous/blood plug (whew!). But it was a wake-up call for me nonetheless, I had gotten too cocky with procedures and needed to be reminded that this is life and death I'm dealing with, and half way through my training is a bad time to be too prideful to ask for help.

During that same shift, I was reminded that I am still woefully uneducated (again, got perhaps a little overconfident in my fledgling diagnostic skills), and it was with an attending that tends to get publicly upset when we overlook things, so I think the three together just devastated me temporarily.

I know we residents are supposed to learn and that Roja and Haemr head are right about being expected to make mistakes, but from the other side it feels like the attendings are thinking "why did I match this person again?"

I am a recovering perfectionist trying very hard to be more accepting of my failures (because I know perfectionism is dangerous in our field), but I am definitely behind my class on that point. Errors and failures seem to run off of everyone else's back. I think I will need to read this thread many times in the coming months!!!

 

[bulgethetwine]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

I had an attending once who said it best: "That's why residency is 3 years (ok, or four) long!".

You will make mistakes. You will make more! And so will I.

The key is to learn from them, and never forget humility. Keep your head up, I feel for you...

 

[Apollyon]

Remember that there are some people in academics that are there because they can't hack it in private practice - the snotty attitude, the poor professionalism, or the lack of quality skills all come together. Some people in academics get their jollies out of cutting people down publicly. When I was a resident, there was one attending like that - he HAD to be right all of the time, and HAD to have the last word all of the time, and would not tolerate ANY disagreement or discussion. This is not conducive to education. It's not a one-way street (as he thought, and I presume still thinks).

It is true - that's why residency is 3 or 4 years. You WILL get better.

 

[kungfufishing]

Funny, when they said it to me they said "KFF, that is why residency is four years...well, ten in your case"

 

[quagmire223]

Thanks all very much for the votes of confidence and support. I feel much better now. I was down in the dumps because I was notified shortly after I left my shift that there had been a complication from my line and I wasn't sure if the patient was dead or alive.

Fortunately what was thought to be a ptx was just a mucous/blood plug (whew!). But it was a wake-up call for me nonetheless, I had gotten too cocky with procedures and needed to be reminded that this is life and death I'm dealing with, and half way through my training is a bad time to be too prideful to ask for help.

You know, you are not the first person to have created a iatrogenic ptx from a line insertion. And even still since you didn't create one. But really, it actually is not uncommon...from both ER and non-ER residents / fellows / even attendings alike.

Also, another important thing is that you are realizing that there are things you need to improve on. Improving them is easier said than done, but recognition is key. I say this because at my own program, there seem to be a couple people who are falling behind...and even with remediation, they still don't seem to realize that they are behind. Faculty can only do so much...the rest of it has to be self-realization and self-motivation.

 

[Haemr Head]

If you haven't dropped a lung doing a central line, you probably haven't done enough central lines.

 

[kungfufishing]

One thing an attending I really liked in residency pointed out to me was "think of all of the procedures you've done that DIDN'T have any complications". She also was fond of encouraging me to "focus on what you know, not on what you don't know". Have to say these were two pieces of advice that stuck with me into my job as an attending.

 

[enfuegoEP]

It's tough all around. Being EM residents doesn't help the ego. Our mistakes are put on the jumbotron and broadcast throughout the hospital. Other services drop lungs all the time, you just don't hear about it. Our mistakes go up to the floor with the patient where everyone can marinate on it. Off service rotation can be filled with people who know a lot more about that specific specialty than you do making you feel constantly behind the curve. It's tough, but we have to push on to the next patient or procedure. Learn from our mistakes but don't dwell on them. We all make mistakes but it's how we respond to them is what counts.

 

[nymbarra]

Hard24Get,

Thanks for starting this thread. You definitely are not alone, at least as 2nd year residents go. We're seeing critical patients, and with the volume, I often find myself feeling like I'm pulled in several directions. Everybody in my class feels this way. When I get home, even though I'm drained, I'll either look up a specific gap or put a post-it on my desktop to look up after I crash. Having this routine helps me to feel like I'm getting better and better everyday, rather than just a resident workhorse.

I really like what the other posters--especially Haemr Head--have to say. My PD had similar advice- he said that the most helpful feedback is not the "good job" ones, but those which actually give detailed ways to improve. They're definitely not the easiest to take, and sometimes they may not seem fair assessments, but at least that is a perception that you did not have of yourself for which to be aware.

Another thing that I've found really helpful is being able to teach a topic. As second years, we get paired with a NP or PA student on our shifts. This has helped me to start working on my talks as well as to identify knowledge gaps--especially those that we've just about forgotten after med school. Then as third year residents, we have more sophisticated 4th year med students to teach. In this transition, I can actually see myself as an attending quoting studies left and right. It'll be awhile, though...

BTW At least three of my classmates have dropped a lung, and two of them have had the most procedural experience! I also put in a chest tube on a trauma patient last month that went to the base. It didn't look pretty and I'm sure the surgeons had a laugh, but it did resolve the patient's pneumo...

 

[enfuegoEP]

I also put in a chest tube on a trauma patient last month that went to the base. It didn't look pretty and I'm sure the surgeons had a laugh, but it did resolve the patient's pneumo...

Yea, but can the surgeons tell you how to prevent the tube going to the base? The answer is no...Yea, you can rotate the tube as you're inserting it yada yada..but even when that's done the tube can still wind up in the base.

 

[EctopicFetus]

Peter Rosen says.. "If you dont feel inadequate as an EP, then you should be worried".

In the end the amount of knowledge we need to have is insane. Am I always 100% right on every patient.. Nope.. I try to make sure I avoid catastrophic mistakes.. but.. its this feeling that keeps me reading and working hard.

When you become complacent you should be very afraid and so should your patients.

 

[deleted109597]

If you haven't dropped a lung doing a central line, you probably haven't done enough central lines.

So, this line is absolutely true. If we're talking about subclavians. It is a common complication.
When you drop one with an IJ, perhaps there is a procedural error that is not a common complication. (ok, if they have severe COPD/bullous disease etc etc etc). Of course, this argues that the gold standard should be US guided direct visualization. If you visualize the needle passing through lung parenchyma, then there's the problem.
If you drop one doing a femoral, you're just plain doing it wrong.

 

[CRN2b]

oops

 

[EM_Rebuilder]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

I think the big question is what year are you? If you are an intern, I would not care about making many mistakes... if you are a senior and will graduate in 6 months, I would be a bit more concerned... Regardless, we are ALL going to make some mistakes in our career.. thats part of the game, if anyone tells you otherwise, they are lying. You hope to avoid the life/limb altering ones...

As far as failing at a procedure, I do not care if you have been an attending for 30 years, there will ALWAYS be an occasional procedure you just cannot get. Maybe its in intubation you call anes or cut the neck on, or a central line after multiple attempts you place an IO or call IR for access. Thats part of the game I suppose...

 

[kungfufishing]

One other good point is that at least for me, there is or was a significant component of vanity involved in feeling crushed when something doesn't go perfectly. The further my short career has progressed, the more I have come to realize that I'm neither as good as I think I am when things are going well nor as bad as I think I am when things are going poorly.

 

[Zanegray]

Last week - my attending, who is greattttt at procedures, missed an LP. We had to start empiric antibiotics for headache and fever in a neutropenic patient . On the floor, Patient got LP under IR - traumatic tap! Suspecting meningitis but cultures not growing anything. Point is, everyone misses sometimes. (I was so relieved it wasn't me)

Also - had a tension pneumo on a patient the other day, after decompression and chest tube insertion, put in a subclavian line. when I talked to the ICU I made sure they knew the order that it occurred in! No one ever gives a us a break on the floors. Point is, I guess you just have to let it go!

Relax and have a happy holiday all!!!!

 

[roja]

(and I remember you from your interview here in Boston. If you were last in your class, it would be a far better class than any I have ever seen. Based on your concerns, I wish we had been able to recruited you! You seem to have the characteristics I look for in a resident in the early years of training - self awarness and the need to excel. Roja and her team are lucky to have you. ).

sadly she isn't with my team, but maybe when she is done!

RE: learning from mistakes.

I am in an academic faculty fellowship with a leader in medical education research etc and attendings from multiple fields. We have been having an ongoing discussion of this actual point. Most people will tell you the things we have learned the most from are our failures. Sometimes it is much harder to learn from our successes because we don't reflect on them, look at them analytically, etc. This has been uniform in all the fields represented.

I think as faculty, its important to be transparent and share our own failures with residents and I do this regularly. To often residents semi-deify faculty adn this reinforces the sense of failure.

We also, in medical education, tend to fall victim to training students and residents into acclimating them to a praise diet. I have read this article several times and continue to go over it to try and improve my feedback and educational skills. "Feedback in medical education.J Ende - J Am Med Assoc, 1983"

Its older but still INCREDIBLY relevant

 

[RandomAttending]

I know it's been a long time, but I have a problem now so I'm back . I feel like my confidence just takes a nose dive every time I screw up. Yes, I know humility is a good thing, but every time I present a patient at rounds and a knowledge deficit or failure to catch an obvious diagnosis is revealed, or I fail at a procedure, I am devastated.

I feel like the least competent person in my class (which I may be), and that I should quit and become a housewife. My attendings and seniors say it's expected for me to screw up, but I just feel so terrible . Any ideas for coping/improving?

You gotta be strong here. This is normal. Don't quit. This happens throughout your career but you must do what is necessary to get your confidence up -- whether that means readiing more or spending more time doing procedures in which you are deficient. Ask you PD for guidance or another attending you trust.

 

[RandomAttending]

If you haven't dropped a lung doing a central line, you probably haven't done enough central lines.

Agreed. HAEMR gives awesome advice!

 

[cleothecat]

Just do not get too cocky.
if you think you are not making mistakes or missing things, then you are just probably too
insensitive or cocky, and potentially dangerous.

It is OK to dwell om "mistakes,errors and ommisions" for a short period in order to assess, and then improve skills and techniques.

I remember as an attending having completed hundreds of subclavian lines in patients with no platelets and feeling too damn sure of myself.
And then I dropped the lung with tension pneumo on the father of a major referring physician.
Lots of "soul searching" after that one.