Feel incompetent and nervous about residency

[IonClaws]

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I am aware that many have posted this sort of thread before. Now it's my turn.

I'm a 4th year med student going into Neurology residency and starting PGY-1 in July this year.

At this point, I feel slightly more competent than I did in the beginning of M3 year. However, I do not, at all, feel competent as a medical student/physician despite passing all required tests and rotations. I forget to ask things a lot and medical facts tend to not stick, and though I'm improved from when I started rotations, I'm nowhere near what you would call polished, and I'm really nervous about starting PGY-1 year. Basically I feel slightly more useful than a hospital volunteer (less so than a scribe) and I'm expected to begin to make medical decisions in less than 3 months.

I'm sure there's others feeling this way but I'd like to hear about it.

 

[Raryn]

Everyone feels this way. I'd be more worried if you didn't.

 

[GoSpursGo]

If you were competent coming out of med school, there would be no need for residency. The scary interns are the ones that think they don't need supervision.

 

[Dral]

Story:

First day of intern year: *Walking across street to the hospital realizes that he doesn't have his stethoscope. Walks back to parking garage and sees stethoscope on top of car*

I thought to myself "So this is how this year is going to be?"

It actually wasn't bad and I sort of have fond memories of it (except for ICU...that was the worst month and week of my life).

You'll survive to tell the tale as well.

...and just so you know, as long as you are going to a reputable program, you will pretty much only be given the illusion of making the important medical decisions at the start. Any good resident/attending worth their weight will have you on a short leash at the beginning of the year.

However, not too far in, you'll be fine to make the decision without supervision to put that new MI admit patient on a cardiac diet though. 😉

 

[NotAProgDirector]

I couldn't remember how to replace potassium on my first day of internship. I turned out OK. Probably.

 

[gutonc]

I couldn't remember how to replace potassium on my first day of internship. I turned out OK. Probably.

...ish

 

[NITRAS]

I sucked it up bad in medical school. I became a chief resident. Took about 6 months for it to click.

 

[Perrotfish]

I couldn't remember how to replace potassium on my first day of internship. I turned out OK. Probably.

I know of one Intern who didn't know how to replace potassium, so he guessed and ordered it IV push. Pharmacy said no.

 

[Siggy]

Medical school taught you what to do... residency teaches you how to do it. The vast majority of people have no clue what they're doing when they start residency because that's the purpose of residency.

 

[GoSpursGo]

I know of one Intern who didn't know how to replace potassium, so he guessed and ordered it IV push. Pharmacy said no.

This is another thing to remember--the pharmacists, nurses, your senior, your attending, and probably your patient all don't trust you either. So if you do try to make a stupid mistake, chances are that someone will catch it before it actually causes harm.

Of course, the time that it isn't caught, there will be an M&M, so you should definitely ASK rather than guessing! But my point is you're not actually doing anything on your own at the beginning and the system is set up to help you learn rather than let you fall on your face.

 

[NeurologyHopeful2018]

I know of one Intern who didn't know how to replace potassium, so he guessed and ordered it IV push. Pharmacy said no.

I thought you do replace K with KCL through IV??

 

[Raryn]

I thought you do replace K with KCL through IV??

Slow infusion. Typically no more than 10meq over an hour through a peripheral IV or 20meq per hour through a cvc.

IV push can lead to tissue necrosis if it infiltrates... And cardiac arrythmias if it's a big dose.

Big dose IV push KCl is how they do lethal injections.

 

[NeurologyHopeful2018]

I am aware that many have posted this sort of thread before. Now it's my turn.

I'm a 4th year med student going into Neurology residency and starting PGY-1 in July this year.

At this point, I feel slightly more competent than I did in the beginning of M3 year. However, I do not, at all, feel competent as a medical student/physician despite passing all required tests and rotations. I forget to ask things a lot and medical facts tend to not stick, and though I'm improved from when I started rotations, I'm nowhere near what you would call polished, and I'm really nervous about starting PGY-1 year. Basically I feel slightly more useful than a hospital volunteer (less so than a scribe) and I'm expected to begin to make medical decisions in less than 3 months.

I'm sure there's others feeling this way but I'd like to hear about it.

Anyone who can graduate from medical school, pass all the boards, and match into a specialty of moderate competitiveness is more than competent enough to handle intern year.

 

[Researchie]

And what if you still struggle to detect heart sounds in some patients? How bad is that?

 

[gutonc]

And what if you still struggle to detect heart sounds in some patients? How bad is that?

Which ones? The Lub, or the Dub?

 

[Researchie]

Which ones? The Lub, or the Dub?

Both at times, unfortunately, most often on overweight patients.

I'm one of those people who does well on tests and struggles with clinical skills and physical exam skills. I just don't want to be making a post on "fired as PGY1--what now?" in a few months.

 

[Raryn]

And what if you still struggle to detect heart sounds in some patients? How bad is that?

I'm a board certified internist 5 years out from med school graduation. I still struggle to detect heart sounds in some of the bigger patients.

If you're worried, order an echo 😉

 

[GoSpursGo]

I'm one of those people who does well on tests and struggles with clinical skills and physical exam skills.

The person you are describing is a medical student/July intern 🙂

 

[Psai]

I know of one Intern who didn't know how to replace potassium, so he guessed and ordered it IV push. Pharmacy said no.

I mean it's really IT's fault for leaving that as an option.

 

[cbrons]

I know of one Intern who didn't know how to replace potassium, so he guessed and ordered it IV push. Pharmacy said no.

Would be the correct decision for lethal injection though.

 

[Mad Jack]

I haven't done any medicine in months. As a soon-to-be psychiatry intern that's going to have to survive four months of medicine and two months of neurology, I'm terrified

 

[clausewitz2]

I haven't done any medicine in months. As a soon-to-be psychiatry intern that's going to have to survive four months of medicine and two months of neurology, I'm terrified

The last inpatient medicine rotation I did before starting on a busy inpatient medicine ward as a psych intern was April of my 3rd year. I did just fine, and you probably will too.

 

[b52bomber]

You'll learn fast. Rely on your senior, don't be afraid to call pharmacy with drug questions.

 

[Siggy]

And what if you still struggle to detect heart sounds in some patients? How bad is that?

Depends, does the patient actually have heart sounds... or should you be calling a code?

 

[Researchie]

Depends, does the patient actually have heart sounds... or should you be calling a code?

That's the problem--I struggle to detect heart sounds such that I fear I will not be able to tell if I can't hear them or if the patient actually does not have them. My last preceptor said that I was performing below what was expected of me on my last rotation. It's not just normal pre-intern nerves--I really am doing pretty terribly. I tried to get an extra medicine rotation end of fourth year, but couldn't.

 

[IonClaws]

That's the problem--I struggle to detect heart sounds such that I fear I will not be able to tell if I can't hear them or if the patient actually does not have them. My last preceptor said that I was performing below what was expected of me on my last rotation. It's not just normal pre-intern nerves--I really am doing pretty terribly. I tried to get an extra medicine rotation end of fourth year, but couldn't.

I don't speak from experience but....couldn't you just check for a pulse?? You can even see if the rate is regular or not from that, AFAIK...

 

[Aonyx]

If the patient is breathing and looking at you, they have heart sounds. If not, and they previously were, try to wake them up by yelling at them or vigorously shaking their chest. If still not looking at you or breathing, jam your fingers into their carotid or femoral artery or where you expect them to be and check for a pulse and then you still want to call for help if they’re suddenly a GCS3 and not breathing. It’s very rare that you aren’t sure something is seriously wrong or not and heart sounds very rarely provide the answer. Even a pulseless person may have heart sounds from valves closing.


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[operaman]

That's the problem--I struggle to detect heart sounds such that I fear I will not be able to tell if I can't hear them or if the patient actually does not have them. My last preceptor said that I was performing below what was expected of me on my last rotation. It's not just normal pre-intern nerves--I really am doing pretty terribly. I tried to get an extra medicine rotation end of fourth year, but couldn't.

On behalf of all the surgical folks here, I know at least one resident very well who hasn’t carried a stethoscope in a few years and can’t remember the last time he had to listen for heart sounds. Obviously medicine folks can’t get away with that, but it shows the relative importance of cardiac auscultation.

If your preceptor meant that your auscultation was not up to par, I wouldn’t worry about it. If your overall knowledge and clinical thinking are substandard then you should be concerned.

You’ll learn a LOT once intern year starts, and until you feel completely comfortable just make sure you’re running things by your seniors. Once you do feel comfortable, you should still be running things by your seniors. In the beginning you may be asking for more help because you don’t know what to do or you’re afraid of missing things. As you grow, you’ll still loop them in but it may be more “patient came in with X so I’ve done A, B and C already and studies D and E are pending. My overall plan is Y and Z. Sound good to you?”

 

[evilbooyaa]

On behalf of all the surgical folks here, I know at least one resident very well who hasn’t carried a stethoscope in a few years and can’t remember the last time he had to listen for heart sounds. Obviously medicine folks can’t get away with that, but it shows the relative importance of cardiac auscultation.

If your preceptor meant that your auscultation was not up to par, I wouldn’t worry about it. If your overall knowledge and clinical thinking are substandard then you should be concerned.

You’ll learn a LOT once intern year starts, and until you feel completely comfortable just make sure you’re running things by your seniors. Once you do feel comfortable, you should still be running things by your seniors. In the beginning you may be asking for more help because you don’t know what to do or you’re afraid of missing things. As you grow, you’ll still loop them in but it may be more “patient came in with X so I’ve done A, B and C already and studies D and E are pending. My overall plan is Y and Z. Sound good to you?”

The bolded was some of the best advice I was given - tell the attending or senior resident what your plan is rather than just asking what that person would do in that situation.

 

[Raryn]

The bolded was some of the best advice I was given - tell the attending or senior resident what your plan is rather than just asking what that person would do in that situation.

With the caveat being that the "I've already done A, B, and C" portion isn't appropriate day one.

That is, day one, it should be "I plan on doing A, B, and C for diagnosis, meanwhile treating with Y, and Z". By midway through intern year, you can transition to "I've already ordered A/B/C and will continue with Y and Z", but ordering stuff before running it by your senior on your first one or two ward months is not a good idea.

 

[evilbooyaa]

Yes, completely agree. I'm in an outpatient specialty so nothing is "I've already done X,Y, and Z", but that is more relevant for inpatient stuff.

 

[operaman]

The bolded was some of the best advice I was given - tell the attending or senior resident what your plan is rather than just asking what that person would do in that situation.

Same here. I remember a chief who would say don't ever call an attending with a question, call them with a plan (that early on you have discussed with said chief).

I think a version applies for calling your seniors as an intern as well, and definitely agree with the poster above who noted don't actually DO anything without running it by anyone in the beginning.

You know, we read a lot about defensive medicine where docs order zillions of tests to cover their bums. Running things up the chain of command is the intern and residents method of defensive medicine. Remember that one of the first things the faculty will ask at M&M is when the chief and attending were notified and what the team's plan was. If you go rogue, nobody can defend you.

 

[john pelley]

I am aware that many have posted this sort of thread before. Now it's my turn.

I'm a 4th year med student going into Neurology residency and starting PGY-1 in July this year.

At this point, I feel slightly more competent than I did in the beginning of M3 year. However, I do not, at all, feel competent as a medical student/physician despite passing all required tests and rotations. I forget to ask things a lot and medical facts tend to not stick, and though I'm improved from when I started rotations, I'm nowhere near what you would call polished, and I'm really nervous about starting PGY-1 year. Basically I feel slightly more useful than a hospital volunteer (less so than a scribe) and I'm expected to begin to make medical decisions in less than 3 months.

I'm sure there's others feeling this way but I'd like to hear about it.

Assuming responsibility for a patient does not imply that you make all of the decisions. That grows with your experience and your experience will be supported by attending physicians. If you want to have more confidence in what your program director really wants, then get ahead of the curve and evaluate yourself on each of the 13 EPAs. These entrustable professional activities are what program directors want on day one of PG1. I will try to upload the AAMC Learners Guide for you to understand more. Note that this is very recent and very important. You will be unique just from being aware of the EPAs. You will understand best if you read and compare both the descriptions and vignettes for pre-entrustable and for entrustable. Look closely and you will see that pre-entrustable thinking is robotic. The desirable entrustable thinking is integrative and anticipatory.

 

[Dires]

You’re going to spend you’re whole intern year feeling somewhat incompetent. Get used to it.

 

[JustPlainBill]

Assuming responsibility for a patient does not imply that you make all of the decisions. That grows with your experience and your experience will be supported by attending physicians. If you want to have more confidence in what your program director really wants, then get ahead of the curve and evaluate yourself on each of the 13 EPAs. These entrustable professional activities are what program directors want on day one of PG1. I will try to upload the AAMC Learners Guide for you to understand more. Note that this is very recent and very important. You will be unique just from being aware of the EPAs. You will understand best if you read and compare both the descriptions and vignettes for pre-entrustable and for entrustable. Look closely and you will see that pre-entrustable thinking is robotic. The desirable entrustable thinking is integrative and anticipatory. You can understand more about developing this type of thinking by searching for the SuccessTypes Medical Education Site - a free access project of mine. jp

This......upon entry of my intern year, I was constantly checking with my seniors. My mentality was that I did not want to be the intern that shoved a patient over the edge. Instead of taking a more (and I hate this term) proactive approach, I always checked things with my seniors. It came across as a lack of confidence -- and I got beaten the hell up for it. It put me under the microscope and went downhill from there. No expectations were stated, ever...if I had had this little guideline, things would likely have been a lot different.