Drowning 4th Year - Residency Doubts

[snaliger]

I am at the beginning of my fourth year and I seriously am doubting my abilities to do well in residency or match. I have been receiving mixed feedback throughout my third and fourth year regarding my clinical skills. Some people tell me I'm doing well (lying? don't know where I should be? too nice? can't vocalize my deficiencies?) and others are very concerned about my clinical skills. I feel like my biggest issue is coming up with a differential and plan in the short amount of time that I have or being able to organize my presentations well without writing up the entire note beforehand. I know I can do a great job if I have endless amounts of time, but then again, who can't? Part of medicine is being efficient and I am so incredibly slow. I suppose it doesn't help that I have so much anxiety about doing well in the mornings on rounds that I can't focus well.

Third year was supposed to be amazing and it has just been a steep upward climb. I think it's one thing to work hard and feel like you're getting somewhere and that it's paying off. But when all your hard work isn't quite enough (or is enough for some and not for others), it can be super frustrating. I don't have any obvious red flags. I've so far passed all my rotations and exams but I just feel like I'm flying under the radar, barely making it. Sometimes I wonder if it's all in my head but I know it's not because I'll meet with course directors who tell me their concerns (though none of this goes in official records or comments).

I want to go into pediatrics so it's not as if I'm trying to match into something incredibly competitive which is what makes all of this even harder.

Does anyone else feel like this? Like it's all an uphill climb. Like you've been slowly falling behind all year and now it's really starting to catch up with you. I think that is what makes medical school so exhausting for me. Not just putting in the hours and studying for a long time. But feeling like it's never enough. It's demoralizing.

My sister told me yesterday "Smooth seas never made a skilled sailor" but also a broken and drowning boat don't either.

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[NeurologyHopeful2018]

I am at the beginning of my fourth year and I seriously am doubting my abilities to do well in residency or match. I have been receiving mixed feedback throughout my third and fourth year regarding my clinical skills. Some people tell me I'm doing well (lying? don't know where I should be? too nice? can't vocalize my deficiencies?) and others are very concerned about my clinical skills. I feel like my biggest issue is coming up with a differential and plan in the short amount of time that I have or being able to organize my presentations well without writing up the entire note beforehand. I know I can do a great job if I have endless amounts of time, but then again, who can't? Part of medicine is being efficient and I am so incredibly slow. I suppose it doesn't help that I have so much anxiety about doing well in the mornings on rounds that I can't focus well.

Third year was supposed to be amazing and it has just been a steep upward climb. I think it's one thing to work hard and feel like you're getting somewhere and that it's paying off. But when all your hard work isn't quite enough (or is enough for some and not for others), it can be super frustrating. I don't have any obvious red flags. I've so far passed all my rotations and exams but I just feel like I'm flying under the radar, barely making it. Sometimes I wonder if it's all in my head but I know it's not because I'll meet with course directors who tell me their concerns (though none of this goes in official records or comments).

I want to go into pediatrics so it's not as if I'm trying to match into something incredibly competitive which is what makes all of this even harder.

Does anyone else feel like this? Like it's all an uphill climb. Like you've been slowly falling behind all year and now it's really starting to catch up with you. I think that is what makes medical school so exhausting for me. Not just putting in the hours and studying for a long time. But feeling like it's never enough. It's demoralizing.

My sister told me yesterday "Smooth seas never made a skilled sailor" but also a broken and drowning boat don't either.

Your board scores, LOR, and clinical evaluation will determine how well you match...

Your feeling of inadequacy is common - you don't have enough experience yet to formulate an assessment and plan quickly.

 

[sunshine02]

I am at the beginning of my fourth year and I seriously am doubting my abilities to do well in residency or match. I have been receiving mixed feedback throughout my third and fourth year regarding my clinical skills. Some people tell me I'm doing well (lying? don't know where I should be? too nice? can't vocalize my deficiencies?) and others are very concerned about my clinical skills. I feel like my biggest issue is coming up with a differential and plan in the short amount of time that I have or being able to organize my presentations well without writing up the entire note beforehand. I know I can do a great job if I have endless amounts of time, but then again, who can't? Part of medicine is being efficient and I am so incredibly slow. I suppose it doesn't help that I have so much anxiety about doing well in the mornings on rounds that I can't focus well.

Third year was supposed to be amazing and it has just been a steep upward climb. I think it's one thing to work hard and feel like you're getting somewhere and that it's paying off. But when all your hard work isn't quite enough (or is enough for some and not for others), it can be super frustrating. I don't have any obvious red flags. I've so far passed all my rotations and exams but I just feel like I'm flying under the radar, barely making it. Sometimes I wonder if it's all in my head but I know it's not because I'll meet with course directors who tell me their concerns (though none of this goes in official records or comments).

I want to go into pediatrics so it's not as if I'm trying to match into something incredibly competitive which is what makes all of this even harder.

Does anyone else feel like this? Like it's all an uphill climb. Like you've been slowly falling behind all year and now it's really starting to catch up with you. I think that is what makes medical school so exhausting for me. Not just putting in the hours and studying for a long time. But feeling like it's never enough. It's demoralizing.

My sister told me yesterday "Smooth seas never made a skilled sailor" but also a broken and drowning boat don't either.

If it makes you feel any better, I have been feeling the EXACT same way as you and I think a lot of students do. However, everyone makes it somehow

 

[Oso]

I feel like my biggest issue is coming up with a differential and plan in the short amount of time that I have or being able to organize my presentations well without writing up the entire note beforehand.

At this stage, you don't need to be right. I mean, it would be cool, but just try to come up with a reasonable differential and at least some management plan. You'll get better in residency.

Part of medicine is being efficient and I am so incredibly slow

Again, that's what residency is for.

I suppose it doesn't help that I have so much anxiety about doing well in the mornings on rounds that I can't focus well.

I'm the same way. What helped me was to adopt a "whatever" mentality when presenting. I would still prepare and try to know everything about the patient and have at least a decent management plan, but in terms of actually presenting, I would just be like "**** it I've done what I can". Feeling like it was low stakes (even though it's not) helped me relax and actually improved my presentations. I don't know if that makes sense. YMMV.

Third year was supposed to be amazing

Who told you this? Lies.

Does anyone else feel like this?

Yeah, and I'm a brand new peds intern.

I want to go into pediatrics

 

[snaliger]

Your board scores, LOR, and clinical evaluation will determine how well you match...

That's also what concerns me. My clinical evaluations on paper are overall positive but nothing remarkable. They do point out things like "cares about patients" and "hard worker" which I think are the important attributes. As far as LOR, I've asked the people who think I have been doing well and at the right level but there are also very few people who think that and it makes me nervous because I don't really have back up letters then.

If this puts anything in perspective, I hardly felt better than the third years on my team when I was on my sub-I. I did have the more complex patients but I still felt like they weren't so far off even though they were close to the beginning of third year. Maybe they just had more confidence.

 

[NeurologyHopeful2018]

How are your board scores?

They are the most important piece of your application and an objective measure of your knowledge.

 

[solitarius]

Work hard. Be prepared to get your ass kicked in intern year. Work hard. Don't piss people off. Work hard.

 

[michaelrack]

However, everyone makes it somehow

Not everyone..... a few fail to match, and some are fired from residency; though I doubt this will happen to the OP

 

[togaedere]

I’ve been where you are, OP. My biggest concern with starting residency was that I looked good on paper but I just didn’t feel like I was hacking it clinically. I’m on maternity leave at the start of my PGY-3 year now (med peds resident) but definitely can vouch that residency helps a ton.

It’s the old issue of comparing self to others — in this mentality everyone else seems like they have it all handled and you are struggling to just tread water. In reality it’s not like this and a lot of people share what you’re thinking. Especially in peds residency (it’s not like you’re entering a field known for inflated egos, is what I’m saying).

Some tips I have for you:

Try to work smarter, not harder. Know that you will miss stuff, but try not to spend all your time prerounding trying to dig up all the history, thinking this will help you on round. Focus on the chief complaint, look at what has been done for the kiddo already, see if you can fill in the gaps with workup of your own.

Relax, and know you will get better. I used to have mini panic attacks before rounds - it actually took me to get through intern year to actually feel comfortable. I had to shift my mentality - let go of how I was perceived (I like what a previous poster said about imagining that it’s low stakes) and just keep reading and trying to improve.

Ask for help. If you’re anything like me your anxiety will make you think you’re so far behind that you should just keep things to yourself and try to find out things on your own. This was my biggest mistake intern year. Ask for help. If you don’t know something become very comfortable with admitting that. Look stuff up.

It gets better.

I am at the beginning of my fourth year and I seriously am doubting my abilities to do well in residency or match. I have been receiving mixed feedback throughout my third and fourth year regarding my clinical skills. Some people tell me I'm doing well (lying? don't know where I should be? too nice? can't vocalize my deficiencies?) and others are very concerned about my clinical skills. I feel like my biggest issue is coming up with a differential and plan in the short amount of time that I have or being able to organize my presentations well without writing up the entire note beforehand. I know I can do a great job if I have endless amounts of time, but then again, who can't? Part of medicine is being efficient and I am so incredibly slow. I suppose it doesn't help that I have so much anxiety about doing well in the mornings on rounds that I can't focus well.

Third year was supposed to be amazing and it has just been a steep upward climb. I think it's one thing to work hard and feel like you're getting somewhere and that it's paying off. But when all your hard work isn't quite enough (or is enough for some and not for others), it can be super frustrating. I don't have any obvious red flags. I've so far passed all my rotations and exams but I just feel like I'm flying under the radar, barely making it. Sometimes I wonder if it's all in my head but I know it's not because I'll meet with course directors who tell me their concerns (though none of this goes in official records or comments).

I want to go into pediatrics so it's not as if I'm trying to match into something incredibly competitive which is what makes all of this even harder.

Does anyone else feel like this? Like it's all an uphill climb. Like you've been slowly falling behind all year and now it's really starting to catch up with you. I think that is what makes medical school so exhausting for me. Not just putting in the hours and studying for a long time. But feeling like it's never enough. It's demoralizing.

My sister told me yesterday "Smooth seas never made a skilled sailor" but also a broken and drowning boat don't either.

 

[snaliger]

Thanks for all the nice messages and reassuring words!

I just think it's so hard to know where I should be. And yeah my anxiety is probably the number one thing keeping me from really succeeding on the wards and that makes me sad.

Also my step 1 score is not concerning me too much. Step 2 is drowning me because you're supposed to learn by studying in third year and I found it really hard to balance clerkship duties with studying so I'm playing catch up now.

 

[snaliger]

I'm starting to feel hopeless about matching and being a decent resident. My entire application is just meh. I have gotten mostly just passing grades in a honor/high pass/pass/fail system. My step 1 scores is 220s. I actually had to postpone step 2 and now it won't be on my ERAS when I first apply. I don't think anyone wants to write me a letter of recommendation. My summative MSPE comments are mostly positive but that's because they filter out the bad ones. And my sub-I comments were so barebones because they filtered out so many comments. Basically they say that I have an interest in patient care, which really speaks very little to my clinical skills in being able to see, evaluate, present, and communicate to patients (because all those things sucked on my rotation and got moved to formative).

And I just don't feel like I'm going to be a good doctor. Every day is a constant struggle to trick myself into thinking I can do it when deep down I feel like I can't. I just don't think I am strong enough to be a doctor.

People take years off between undergrad and med school. Maybe I should take a year off between med school and residency (though I do run the risk of forgetting a lot)

 

[Perrotfish]

I'm starting to feel hopeless about matching and being a decent resident. My entire application is just meh. I have gotten mostly just passing grades in a honor/high pass/pass/fail system. My step 1 scores is 220s. I actually had to postpone step 2 and now it won't be on my ERAS when I first apply. I don't think anyone wants to write me a letter of recommendation. My summative MSPE comments are mostly positive but that's because they filter out the bad ones. And my sub-I comments were so barebones because they filtered out so many comments. Basically they say that I have an interest in patient care, which really speaks very little to my clinical skills in being able to see, evaluate, present, and communicate to patients (because all those things sucked on my rotation and got moved to formative).

And I just don't feel like I'm going to be a good doctor. Every day is a constant struggle to trick myself into thinking I can do it when deep down I feel like I can't. I just don't think I am strong enough to be a doctor.

People take years off between undergrad and med school. Maybe I should take a year off between med school and residency (though I do run the risk of forgetting a lot)

You sound like you are having problems adapting to a world where you are average. You have mostly been getting the grade that 60% of the class gets on any given rotation. You have a step score within a standard deviation of the national average. In a sea of nearly identical medical students you didn't stand out. For someone who probably spent all of high school and college being the hyper-intelligent overachiever that's a huge adjustment.

Try to remember that being an average medical student doesn't make you an average person, you're just average in the select group of people who have the work ethic and intelligence to get into medical school in the first place. Remember that even in the group of people who got into medical school you aren't the one who is struggling: I promise you that the bottom 10% of your class is having monthly meetings with the Deans to discuss academic remediation and professionalism issues. Remember that average medical students become good physicians. You don't need to be the top 1% of the top 1% to match, or to be a good doctor after residency. Finally remember that almost everyone who studies medicine feels like an incompetent fraud until about midway through Intern year. The handful who graduate thinking that they know what they're doing are really, REALLY dangerous.

Unless you are leaving some huge component of the story out (Multiple failures, foreign grad, major professionalism concerns) do NOT put off the match. Its a big red flag for the match, its a 250K waste of money, and it will make Intern year harder rather than easier. Work with your deans to make sure your goal specialty and match list is appropriate for your stats, and then trust the system.

 

[hmockingbird]

I’m actually going to take a different approach because it seems like this is more than imposter syndrome if you have been pulled aside by clinical directors and had poor eval comments.

I do think this is something everyone struggles with to some extent though!

So a few things:
1. During these meetings did you ask for advice on how to improve? If not I would go back and ask. The education directors usually have experience with med students so may be better at giving specific tips. If you did and didn’t get great answers is there an attending you got along with whom you think would be helpful?
2. During your future rotations I would ask for specific feedback, frequently, from multiple sources. If you can’t get a specific answer then it might help to direct them by picking one thing you want to work on (eg presentations) and asking if they have any tips on that.
3. For pre-rounding it’s easy to get bogged down especially with complicated patients. Yes it does come with time - but here are some things you can try:
-Instead of starting fresh each day keep an ongoing log of the patient’s labs and vitals that you just update (maybe with rows for each vital or lab and columns for each day or however you want to organise it), that way you don’t have to work as hard to understand trends. And you’ll look awesome on rounds if they ask about a lab from three days ago!
-Pre-round the same way on each patient each time. Personally I like to look up vitals, then I/O, then labs, then imaging. THEN I go back and investigate anything that seemed abnormal (I do it this way so I don’t get distracted and forget to look up a whole category entirely and sometimes I will star or circle abnormal items so I remember to check them).
-If you have a complicated patient try to find a recent discharge summary or primary care note which may help you out in terms of giving a good summary of their main issues.
-I also like to memorise my patients’ “one liners”, eg this is a 5yo with sickle cell disease presenting with cough and fever concerning for acute chest syndrome. So now if that’s all I remember for that patient without my paperwork it gives me a lot of info. Sickle cell - I gotta remember to think about its complications and risk factors. Acute chest - that’s my diagnosis plus I understand it’s sickling and maybe an infection in the lungs. Oh yeah this patient has sickle cell! That will help me remember what bugs I might be pimped about and therefore what antibiotics I might choose. For a complicated patient it does help me break it down piece by piece and a one-liner is like an overarching guide with all the “buckets” I should consider first if that makes sense. You can also go backwards in the same manner (patient with chest pain and history of sickle cell... sickle cell may clue you in to acute chest).
-Use a mneumonic for differentials that goes through the different organ systems. Try to think of one for each or a reason why it wouldn’t fit that system. And also remember to include pertinent negatives (eg I don’t think it’s x [major diagnosis to consider with their CC] because y... makes you look smart).
-Try to start your differential as soon as you get a chief complaint. Ok this patient has vomiting. What should I consider? This will also help you think about what questions to ask during the H&P if that’s a problem for you.
-You could use the first aid CS book for a basic differential reference honestly.
-It may also help at some point to jot down some keywords for your differential whether that’s when you first hear the CC or before staffing/presenting. Actually just write down everything! Different exam finding? Write it down so you don’t forget to present it!
-Ask your resident to talk through differentials with you if you have time.
4. Finally if you feel like your anxiety is affecting your ability to focus, especially if you’ve tried a lot of the above, I would consider getting treated.

 

[snaliger]

Everyone has been so nice to me on this forum. It's so great that people can be so nice to be complete stranger.

I agree it is more than imposter syndrome. It is anxiety over a year that has resulted in poor learning. It is lack of background knowledge. It is anxiety in not being able to do everything I want to do in the morning and easily getting distracted. I also find it extremely hard to think in the way of differentials. I'm hoping that through CS studying I can become better at that. Maybe my EM clerkship can help a lot too.

Are you talking about using the VINDICATE mnemonic for differentials?

 

[Freeinfinity]

It’s not unreasonable to feel like this. In fact, I would be more concerned for the ones who think they got it completely down at this level of training. Even the attendings don’t always know everything, hence the term “lifelong learning”. Just acknowledge that there’s still a lot to learn and keep working hard to close that knowledge gap. You’ll get there eventually with enough practice.

 

[Perrotfish]

Everyone has been so nice to me on this forum. It's so great that people can be so nice to be complete stranger.

I agree it is more than imposter syndrome. It is anxiety over a year that has resulted in poor learning. It is lack of background knowledge. It is anxiety in not being able to do everything I want to do in the morning and easily getting distracted. I also find it extremely hard to think in the way of differentials. I'm hoping that through CS studying I can become better at that. Maybe my EM clerkship can help a lot too.

Well if you want to improve clinically you do still have an entire year left. I'm not sure how your school structures 4th year but you might be able get in another two sub-Is (try to make one NICU, if possible) and several pediatric subspecialties. There is no rule that says you need to finish 4th year less prepared for internship than you were at the end of MS3.

If there is a component of disproportionate anxiety, it might be worth addressing that as well. Mental health care.is a lot.easier to establish in MS4 than in intern year.