EM intern - feel incompetent!

[MsFutureDoc123]

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Hey guys!

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

 

[HemeOncHopeful19]

You probably are incompetent. So are your peers. If you weren’t, we wouldn’t need residency!

 

[RainbowOtterz]

You're an intern. It is expected. Just read and try to improve! You'll constantly feel dumb until a about 3/4 the way through the year, then you'll start to feel good, and then you'll start junior year and feel bad again.

 

[Tenk]

If you thought you were as good as an attending in 3 weeks of training you’d be a NP, not a doctor.

Don’t sweat it, this is what residency is for.

 

[TooMuchResearch]

Don't worry. You're incompetent, but competent for level of training.

 

[Groove]

Hey guys!

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

 

[southerndoc]

Everyone felt incompetent their first few months of residency. Don't sweat it. Just keep learning. That's what residency is for!

I still learn things. Made a mistake last night that I learned from. Been practicing for 10 years.

 

[doggydog]

We have an intern bragging that he saw eight patients in a shift last week.

🙄

 

[enalli]

OP, it's normal to feel this way.

Don't study 3-4 hours per day. That's not sustainable long-term. Aim for 1-2 hours per day.

 

[DO3]

Felt incompetent until January of 3rd year. Learn to be comfortable being uncomfortable, but also don’t be afraid to let someone (attending/senior resident) know when you don’t know something, don’t know what to do, or feel overwhelmed.

 

[GonnaBeADoc2222]

OP, I'm so glad you're having the feeling you're having right now. It means you are self aware. It means you know what you don't know and this is totally normal. It also probably means that you can be trusted.

Your co-residents may also start talking about how they're amazing at procedures. Ignore them. We had this one girl intern year who pretended to be gods gift to central lines while inside I knew I was struggling with them and it made me feel like s***. It took me a little while as an intern to learn them but then I was solid.

It also took me about 30 fails at U/S guided peripheral lines to nail them down. Now I almost never miss.

One of our chiefs once said "I've never missed an airway." My response to that is "Well then you never learned anything about airway."

Residency is all about trial and error and gradual improvement. As long as you're motivated and teachable you'll do great.

 

[cyanide12345678]

My first 3 months, I felt so uncomfortable with sick critical patients that I wasn't sure if I picked the right field. It gets better. I sucked and missed cannulation for my first 3 Central lines, started really questioning my procedural ability. That is part of intern year, putting on a brave face and pushing yourself to be better. It takes time to get better. Residency is 3 years for a reason.

Your first few months as a 2nd year, you'll be uncomfortable again, all of a sudden expectations will have gone up. You will be all by yourself in an ICU, just you and 20+ critical patients where often someone will crash and you'll have to take care of it by yourself without an attending holding your hand. The ED will expect that you see more patients and move patients, and the higher volumes will sometimes make you uncomfortable.

Third year, if you moonlight, your first few shifts by yourself, you will feel uncomfortable again. You won't have someone else confirming what you thought was right, you'll doubt even things you know and look up far more up to date or pepid than usual.

Keep grinding. It gets better. No body is born an ER doctor. You train and become comfortable in that role. Good luck.

 

[MsFutureDoc123]

Thank you so much for the feedback everyone! I guess it's just all part of the process. Hopefully by this time next year I'll look back at this time and laugh, haha! 🙂

 

[CajunMedic]

This is round 2 for me (did an EM focused TY last year). I still feel a degree of incompetence. You're learning a new system, new way of doing things, All the quirks of each attending, etc. Attending had this same talk with me this morning. It's expected, and OK at this point in intern year.

 

[deleted859535]

Hey guys!

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

Every year, like clockwork, these threads show up.

1. In our world, 99%+ of interns are unsafe to practice independently with even a mild to moderate complexity case. That's not an insult. That's a fact speaking to why we have residency. Lots of medical knowledge (with even lots more to come) -- and not a great ability to apply it.

2. Most interns who think otherwise are the ones we attendings don't trust because they simply don't know what they don't know. Happily, most of them ultimately "get it" and realize there is a lot to learn, and there is always more to be learned.

3. The ones who scoff at the above are the ones we actively dislike working with because they're incompetent AND dangerous.

Be likable and keep learning - it's not easy, but it is simple. The rest comes with time. You've got this.

 

[Rekt]

I'm having a problem with choosing resources. I have no problem allocating time for studying, more-so I'm overwhelmed with the amount of resources I should be using. I've been reading Tintinalli's everyday, but I honestly think it sucks ass. I feel like it's unnecessarily wordy just for the sake of being wordy with little meat to the chapters. With Rosh, the questions are either too easy or some esoteric minutiae without any in between. What are all you guys using? Attendings/faculty what did you guys use/recommend?

 

[RustedFox]

I'm having a problem with choosing resources. I have no problem allocating time for studying, more-so I'm overwhelmed with the amount of resources I should be using. I've been reading Tintinalli's everyday, but I honestly think it sucks ass. I feel like it's unnecessarily wordy just for the sake of being wordy with little meat to the chapters. With Rosh, the questions are either too easy or some esoteric minutiae without any in between. What are all you guys using? Attendings/faculty what did you guys use/recommend?

Tintialli is awful.
Rosen is worse.

Baby Tintinalli for the framework.

 

[GonnaBeADoc2222]

Literally fell asleep on top of tintinalli once. Woke up with drool on the pages. What a waste of money.

I found that my studying strartegy changed drastically between medical school and residency. In medical school I could spend 5 hours reading without a break. Not so in residency. I really think there's something about the forced multitasking and constant interruptions in the ED that is bad for the human brain and results in a sort of acquired attention deficit disorder. Because of this, it was really difficult for me to do anything but very focussed studying.

Up to date is great for this. See a patient with ureteral stones? Read about it in up to date sometime after shift. See a patient with septic shock? Read about it in up to date. Start with the summary section to make sure you hit the highlights in case you get bored and then dive into the rest of the article. Print out a bunch if you're going on an airplane or train ride.

LITFL, emcrit, rebel em, pedem morsels are foam that I like to sometimes peruse. It's unfortunate though because all the foam I used to really like seems to have undergone changes recently towards flashier websites, and worse content. I used to listen to emrap when I got it for free in residency but they became too campy, starting pandering to midlevels, starting talking about really not worthwhile topics.

 

[Groove]

PGY 1+2: AAEM Black Book and Rosen's for reference, Pepid on your iPhone, reference it before you present to attending/upper level.
PGY 3+: Ref UpToDate during/after shifts/cases to get into more of the nitty gritty details that goes beyond basic references and texts. EM Blogs and online resources like @GonnaBeADoc2222 described.

Uptodate is most useful after you've already gained your core EM knowledge because it gets into a lot of details. I reference it routinely even now, but I'm much more interested in details that go beyond basic EM knowledge at this point in my career. I would save resources that run the risk of missing the forest for the trees until you've attained your basic core knowledge base.

 

[RustedFox]

Tintialli is awful.
Rosen is worse.

Baby Tintinalli for the framework.

Addendum:

I seriously sold the three-volumes of Rosen that were provided to us by our residency program halfway thru intern year to help with whatever costs I had at the time.

I never missed it. Got like 330 bucks for it.

 

[Old_Mil]

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

Three weeks in, this is a pretty normal feeling. When you say, "I haven't done anything the past 6 months of fourth year", what were you doing exactly?

Just a few questions...

(1) Does your residency use an EMR? If so, which one? Do you chart with templates or with dictation? Do you chart at the bedside or after the fact? Is your residency a CMG owned/operated/affiliated residency and what is the patient load you are being asked to see?

(2) When you study 3-4 hours a day, what and how do you study?

(3) When you say your plans are never totally correct, could you expound on that a little more?

 

[Old_Mil]

Tintialli is awful.
Rosen is worse.

Baby Tintinalli for the framework.

Agree. The two best known textbooks are poorly written, poorly edited hot messes.

BTW, Rosen is a hired gun for plaintiff lawyers, I wouldn't put any money in his pocket buying his text.

Harwood-Nuss is an easy to read alternative, but is due for an update. Roberts & Hedges for procedures.

Most importantly get one textbook resource and stick with it. You don't want to try and learn things 2 or 3 different ways.

 

[Old_Mil]

We have an intern bragging that he saw eight patients in a shift last week.

It was pretty much expected that we would be seeing 1 pph by the 6 month mark of our intern year, 2 pph in our second year, and 2+ pph in our third. But this is why I raise the issue of CMG involvement. There are a lot of reasons to want to start an Emergency Medicine residency. Some good, some bad. Bad would involve something like "medicare money + a workforce working for half the rate of a EMPA."

 

[thegenius]

Agree. The two best known textbooks are poorly written, poorly edited hot messes.

BTW, Rosen is a hired gun for plaintiff lawyers, I wouldn't put any money in his pocket buying his text.

Harwood-Nuss is an easy to read alternative, but is due for an update. Roberts & Hedges for procedures.

Most importantly get one textbook resource and stick with it. You don't want to try and learn things 2 or 3 different ways.

These major EM textbooks are written to be like Harrisons for Internal Medicine, they are lengthy and definitive. Problem is ER docs think the opposite of other specialties. We ask for, and require, very little information, act quickly based on pattern recognition, and dispo to the hospital.

So where there are 6 pages on renal colic...all we really need is 6 lines.

Someone has to make the lengthy text. Occasionally I'll reference it even now, maybe once/year.

 

[RustedFox]

Agree. The two best known textbooks are poorly written, poorly edited hot messes.

BTW, Rosen is a hired gun for plaintiff lawyers, I wouldn't put any money in his pocket buying his text.

Years later, when Rosen did Rosen - I reflected on my decision to sell those textbooks and said to myself: "Good call, dude."

 

[Old_Mil]

These major EM textbooks are written to be like Harrisons for Internal Medicine, they are lengthy and definitive. Problem is ER docs think the opposite of other specialties. We ask for, and require, very little information, act quickly based on pattern recognition, and dispo to the hospital.

So where there are 6 pages on renal colic...all we really need is 6 lines.

Someone has to make the lengthy text. Occasionally I'll reference it even now, maybe once/year.

Harrisons is actually a pretty good textbook. The issue with the two big name ED textbooks is not so much the volume of information...it's the quality of the prose, the repetitiousness, the contradictions between different sections written by different authors, and so on.

 

[RustedFox]

Harrisons is actually a pretty good textbook. The issue with the two big name ED textbooks is not so much the volume of information...it's the quality of the prose, the repetitiousness, the contradictions between different sections written by different authors, and so on.

If anyone would pay me to do so, I would totally love to re-write Tintinalli to make it not suck.

Excerpts from Fox's Emergency Medicine:

Literally, like - hundreds of tons of people have COPD exacerbations every day. Get used to it. It sucks for them, so be nice to them. NO, don't "withhold oxygen from them because it might diminish their respiratory drive". Knock it off. That's nonsense.

Kidney stones happen every day, all day - but don't be tricked! LOTS of things can look like a kidney stone. Diverticulitis. Appendicitis. Triple-A. If you get tricked; then join the club. We get tricked, like - ALL the time. The IM mouthbreathers like to act like they don't get tricked, but they freak out and spiral if they have to manage 2+ patients at once.

Subarachnoid hemorrhage?! Yeah, that like, never happens - but you have to look out for it. Pain in the ass, I know. Document a reallllly good neck exam, and just order the CT/CTA combo meal. If they're not better after the medicines... you have to stick a needle in their back. Sedate them when you do that, because their headache is going to be worse when your LP is negative and you won't feel so bad afterwards.

Mitral valve prolapse? Chronic lyme syndrome? Fibromyalgia? Irritable bowel syndrome? LOLz. Guess what?! We all get tired, have palpitations, get bummed, and have diarrhea (especially if you like Mexican food). When a patient mentions 2+ of these things to you during H&P... just space out and let them talk for a few minutes. I like to imagine what would happen if I actually had to run thru World 5-1 of Super Mario Brothers 3 in -real life-. Its not an easy level, and there are plenty of value-decisions to be made. Then, order whatever you want. It doesn't matter. For real. Discharge them after all labs are normal.


I could go on, man.

 

[TrashPanda13]

PGY 1+2: AAEM Black Book and Rosen's for reference, Pepid on your iPhone, reference it before you present to attending/upper level.

Stupid question, but is this book the one that literally has a black cover? Looking on the AAEM site, there's only one and it's the written review book.

Hey guys!

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

I'm also wrapping up my first month and I just feel overwhelmed and disappointed in myself. I go into every shift thinking "I'm going to be better than I was yesterday" and inevitably, I walk away feeling like I did worse. Missing questions on the history, taking a longer time with my initial visit than my seniors, not knowing what to order or do, answering all the "pimp" questions incorrectly, f***ing up a procedure, trying to figure out how to work with the tough attendings, praying that the medical knowledge I had as a 4th year sub-I comes back soon, learning how to document an MDM properly, being slow and inefficient, understanding the logistics of my hospital, etc. On top of all that, I'm failing our weekly quizzes badly despite doing the readings and normally being a good test-taker.

I feel ashamed at how stupid and incompetent I am, and I always want to apologize to my seniors and attendings for being a disappointment. Most of the time, I don't ever believe I'll become a competent, let alone great, emergency physician. I also thought that I was the only one that felt this way. But you know what? The rest of my class feels similarly, and all my seniors have said that they felt the same way when they were in my shoes.. Heck, my chief resident told me that he still feels the same way at times. I've come to terms that it's all just growing pains. I just keep telling myself to focus on the growing and not letting the pain get me down. Easier said than done, and I'm constantly beating myself up and having stress/anxiety/whatever you want to call it, but I've been told to just trust the process and put in the work.

 

[VA Hopeful Dr]

If anyone would pay me to do so, I would totally love to re-write Tintinalli to make it not suck.

Excerpts from Fox's Emergency Medicine:

Literally, like - hundreds of tons of people have COPD exacerbations every day. Get used to it. It sucks for them, so be nice to them. NO, don't "withhold oxygen from them because it might diminish their respiratory drive". Knock it off. That's nonsense.

Kidney stones happen every day, all day - but don't be tricked! LOTS of things can look like a kidney stone. Diverticulitis. Appendicitis. Triple-A. If you get tricked; then join the club. We get tricked, like - ALL the time. The IM mouthbreathers like to act like they don't get tricked, but they freak out and spiral if they have to manage 2+ patients at once.

Subarachnoid hemorrhage?! Yeah, that like, never happens - but you have to look out for it. Pain in the ass, I know. Document a reallllly good neck exam, and just order the CT/CTA combo meal. If they're not better after the medicines... you have to stick a needle in their back. Sedate them when you do that, because their headache is going to be worse when your LP is negative and you won't feel so bad afterwards.

Mitral valve prolapse? Chronic lyme syndrome? Fibromyalgia? Irritable bowel syndrome? LOLz. Guess what?! We all get tired, have palpitations, get bummed, and have diarrhea (especially if you like Mexican food). When a patient mentions 2+ of these things to you during H&P... just space out and let them talk for a few minutes. I like to imagine what would happen if I actually had to run thru World 5-1 of Super Mario Brothers 3 in -real life-. Its not an easy level, and there are plenty of value-decisions to be made. Then, order whatever you want. It doesn't matter. For real. Discharge them after all labs are normal.


I could go on, man.

I'm not even EM and I'd buy that book

 

[Groove]

Stupid question, but is this book the one that literally has a black cover? Looking on the AAEM site, there's only one and it's the written review book.

Yes, I'll update my original post. Here's the link:

Amazon product ASIN 1938827147
It's the perfect balance between details and length in an easy to read/remember format. What's better is that it helps you learn/remember the important stuff. (i.e. What's on your BOARDS)

 

[Old_Mil]

If anyone would pay me to do so, I would totally love to re-write Tintinalli to make it not suck.

Excerpts from Fox's Emergency Medicine:

Literally, like - hundreds of tons of people have COPD exacerbations every day. Get used to it. It sucks for them, so be nice to them. NO, don't "withhold oxygen from them because it might diminish their respiratory drive". Knock it off. That's nonsense.

Kidney stones happen every day, all day - but don't be tricked! LOTS of things can look like a kidney stone. Diverticulitis. Appendicitis. Triple-A. If you get tricked; then join the club. We get tricked, like - ALL the time. The IM mouthbreathers like to act like they don't get tricked, but they freak out and spiral if they have to manage 2+ patients at once.

Subarachnoid hemorrhage?! Yeah, that like, never happens - but you have to look out for it. Pain in the ass, I know. Document a reallllly good neck exam, and just order the CT/CTA combo meal. If they're not better after the medicines... you have to stick a needle in their back. Sedate them when you do that, because their headache is going to be worse when your LP is negative and you won't feel so bad afterwards.

Mitral valve prolapse? Chronic lyme syndrome? Fibromyalgia? Irritable bowel syndrome? LOLz. Guess what?! We all get tired, have palpitations, get bummed, and have diarrhea (especially if you like Mexican food). When a patient mentions 2+ of these things to you during H&P... just space out and let them talk for a few minutes. I like to imagine what would happen if I actually had to run thru World 5-1 of Super Mario Brothers 3 in -real life-. Its not an easy level, and there are plenty of value-decisions to be made. Then, order whatever you want. It doesn't matter. For real. Discharge them after all labs are normal.

I could go on, man.

 

[LostinLift]

Stupid question, but is this book the one that literally has a black cover? Looking on the AAEM site, there's only one and it's the written review book.



I'm also wrapping up my first month and I just feel overwhelmed and disappointed in myself. I go into every shift thinking "I'm going to be better than I was yesterday" and inevitably, I walk away feeling like I did worse. Missing questions on the history, taking a longer time with my initial visit than my seniors, not knowing what to order or do, answering all the "pimp" questions incorrectly, f***ing up a procedure, trying to figure out how to work with the tough attendings, praying that the medical knowledge I had as a 4th year sub-I comes back soon, learning how to document an MDM properly, being slow and inefficient, understanding the logistics of my hospital, etc. On top of all that, I'm failing our weekly quizzes badly despite doing the readings and normally being a good test-taker.

I feel ashamed at how stupid and incompetent I am, and I always want to apologize to my seniors and attendings for being a disappointment. Most of the time, I don't ever believe I'll become a competent, let alone great, emergency physician. I also thought that I was the only one that felt this way. But you know what? The rest of my class feels similarly, and all my seniors have said that they felt the same way when they were in my shoes.. Heck, my chief resident told me that he still feels the same way at times. I've come to terms that it's all just growing pains. I just keep telling myself to focus on the growing and not letting the pain get me down. Easier said than done, and I'm constantly beating myself up and having stress/anxiety/whatever you want to call it, but I've been told to just trust the process and put in the work.

You are being way too hard on yourself for the wrong reasons. Making mistakes (with attending/senior resident oversight) is expected and NECESSARY for your learning. Having a hard shift and getting feedback on what you did wrong is a GOOD thing. This is how you learn. You might forget to ask people with skin breaks about their tetanus status the first 50-100 times. But then slowly (or very quickly), you'll start to remember. You need to change your mindset and look at mistakes and failures as a positive thing.

Did you watch Arnold's video that @Groove posted? You really should. To quote Arnie, "Don't be afraid of failing, because there is nothing wrong with failing. You have to fail in order to climb that ladder. There is no one that doesn't fail. We all fail, it's OK. What is not OK, is that when you fail you stay down. Whoever stays down is a loser. And winners will fail, and get up, fail and get up, fail and get up. You always get up - THAT is a winner."

 

[Birdstrike]

Hey guys!

So it’s been about 3 weeks now of EM intern year and I feel incredibly incompetent! I feel like I’m missing things in my history that the attending gets after, my plans are never totally correct, and I just feel incompetent! I feel like my colleagues, at least from afar, are more prepared. I haven’t done anything the past 6 months of fourth year and feel like it’s coming back but slowly.

I’ve been trying to study like 3-4 hours a day to compensate which I heard is a lot, but every day still feels like a setback. Is this at all a normal experience just starting out? Any suggestions?

It's normal to feel incompetent an an EM intern. It goes away as your training progresses. You'll feel competent in a few months. By your 3rd year you'll feel confident. Then your first shift as an attending, you start to doubt yourself again. That also is normal. It's also for that to go away as time progresses, also. This is a cycle that repeats when you cross each milestone threshold. Embrace it and plow ahead.

 

[TooMuchResearch]

"Thanks for 1000 words on the epidemiology of kidney stones, now I'm too tired and bored to read the useful part."

I still own The Atlas of Emergency Medicine, but I recently found it online in our hospital resources, so not sure there is a good reason to keep the thing.

These major EM textbooks are written to be like Harrisons for Internal Medicine, they are lengthy and definitive. Problem is ER docs think the opposite of other specialties. We ask for, and require, very little information, act quickly based on pattern recognition, and dispo to the hospital.

So where there are 6 pages on renal colic...all we really need is 6 lines.

Someone has to make the lengthy text. Occasionally I'll reference it even now, maybe once/year.

 

[TooMuchResearch]

I remember when I was a third year the first year residents would sometimes disappear for 30 minutes. They were taking the world's longest histories. And then screwing up their plans because they couldn't figure out what was important in the mess they just took down. They got better, a couple of them are starting with our group soon.

You're supposed to suck.
Can't speak to whatever these weekly quizzes are. We had no such things.

Stupid question, but is this book the one that literally has a black cover? Looking on the AAEM site, there's only one and it's the written review book.



I'm also wrapping up my first month and I just feel overwhelmed and disappointed in myself. I go into every shift thinking "I'm going to be better than I was yesterday" and inevitably, I walk away feeling like I did worse. Missing questions on the history, taking a longer time with my initial visit than my seniors, not knowing what to order or do, answering all the "pimp" questions incorrectly, f***ing up a procedure, trying to figure out how to work with the tough attendings, praying that the medical knowledge I had as a 4th year sub-I comes back soon, learning how to document an MDM properly, being slow and inefficient, understanding the logistics of my hospital, etc. On top of all that, I'm failing our weekly quizzes badly despite doing the readings and normally being a good test-taker.

I feel ashamed at how stupid and incompetent I am, and I always want to apologize to my seniors and attendings for being a disappointment. Most of the time, I don't ever believe I'll become a competent, let alone great, emergency physician. I also thought that I was the only one that felt this way. But you know what? The rest of my class feels similarly, and all my seniors have said that they felt the same way when they were in my shoes.. Heck, my chief resident told me that he still feels the same way at times. I've come to terms that it's all just growing pains. I just keep telling myself to focus on the growing and not letting the pain get me down. Easier said than done, and I'm constantly beating myself up and having stress/anxiety/whatever you want to call it, but I've been told to just trust the process and put in the work.