Feeling like an intern all over again

[Psychresy]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

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[littlefred]

Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

Time.

 

[comp1]

Talk to everybody. Check in with the nurses. Check in with the front desk staff. If there are social workers, meet them. Meet the techs. Make everything you do a team effort.

 

[deleted1100659]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

This means you have the insight to verify and double check things and to ensure the clinicals decisions you're making are the right ones/best ones at that time. The ones who never have any doubt and assume they're 100% correct 100% of the times are the ones that concern me.

Keep uptodate on your phone and medscape, dont be afraid to reference it. Uptodate app is quite handy, ive used it quite frequently for various stuff. I use medscape for medication pharmokinetics because its quick/easy to use. Sometimes other stuff as well like dosing.

 

[clausewitz2]

Keep uptodate on your phone and medscape, dont be afraid to reference it. Uptodate app is quite handy, ive used it quite frequently for various stuff. I use medscape for medication pharmokinetics because its quick/easy to use. Sometimes other stuff as well like dosing.

Second this. Even if you think you know the dosing of a med pretty darn well, don't hesistate to use a quick information source to verify you're not doing anything crazy because it is way too easy to get into second-guessing yourself otherwise if you are inclined to do so.

This is actually a good thing for you to be experiencing during training, hopefully it will reduce the length of the similar period you absolutely 100% will experience when you become a new attending.

 

[Sushirolls]

Time as mentioned above.
Do more moonlighting!
Give it 3-9 months and you'll feel this pass.
The harder part, is when you are doing your normal residency rotations continuing to be in the resident box mindset. Supervision and oversight starts to feel painful and the yearning to be done and out, mounts. Metaphorically you'll feel like a husky on the sled, but the driver still has the brake on while your digging in giving it all you got.

 

[MedMan80]

I'm on my third year and finally feeling comfortable with patients/right mix of empathy, that I need to be a good psychiatrist.

 

[clausewitz2]

I'm on my third year and finally feeling comfortable with patients/right mix of empathy, that I need to be a good psychiatrist.

Sounds about right, I'm two years out, and most days there are only a few patients who still provoke that terrified internal scream.

 

[J ROD]

Find your inner "Batman". What would Batman do......

 

[Crayola227]

Find your inner "Batman". What would Batman do......

lol I'm about 20 min in to the new one right now (we only get to watch during baby's naps... so like, it will take us about 9 naps to watch the whole movie!) and it seems like a lot of WWBD ends up being punch someone in the face repeatedly until they stop moving... which I dunno, could be a new way to approach a lot of medical problems.... you can't really suffer if you're unconscious. Which sounded like a novel idea for a second until I realized that's how a lot of patients approach self treatment. Sigh. Back to the drawing board I guess.

 

[J ROD]

Use the utility belt of knowledge

 

[Mad Jack]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

As someone that very recently had a similar experience I've got to say it gets better. The hard part for me was the workload- when I moonlight I see about three times as many patients as I saw on a typical intern shift in psych. It's an adjustment but you manage, and it's a big part of your growth as a physician. Second everyone above with regard to UptoDate, Medscape, and building a good bond with staff. Much as in intern year, a good nurse can save your ass when they know patients you are just meeting for the first time. They'll tell you something is off, or if things seem fine, and can be a great compass.

 

[Mad Jack]

Sounds about right, I'm two years out, and most days there are only a few patients who still provoke that terrified internal scream.

I think the hardest thing for me was going from residency to moonlighting in inpatient community settings where psychiatrists around here do a lot more med-psych. When half my patients were 60+ and had piles of meds and equally large piles of comorbidities, going from third year of psych to managing diabetes and hypertension again in elderly or near-elderly patients felt challenging, and still does

 

[calvnandhobbs68]

The harder part, is when you are doing your normal residency rotations continuing to be in the resident box mindset. Supervision and oversight starts to feel painful and the yearning to be done and out, mounts. Metaphorically you'll feel like a husky on the sled, but the driver still has the brake on while your digging in giving it all you got.

Yeah that's why I liked indirect supervision outpatient. I had one direct supervision clinic still my last year and it was pretty painful. I was much more in the "if I have a question I'll ask you" status at that point.

OP agree with everyone else, don't be afraid to reference sources frequently, check med interactions frequently, etc. It's actually great practice for having the complete liability as an attending.

 

[Psychresy]

I think the hardest thing for me was going from residency to moonlighting in inpatient community settings where psychiatrists around here do a lot more med-psych. When half my patients were 60+ and had piles of meds and equally large piles of comorbidities, going from third year of psych to managing diabetes and hypertension again in elderly or near-elderly patients felt challenging, and still does

How deep into the diabetes management algorithm are we talking here...?

 

[Mad Jack]

How deep into the diabetes management algorithm are we talking here...?

Not too deep, basic management of ongoing diabetes. But converting outpatient to inpatient formulary insulin is a headache I hadn't had to deal with in a while, and the way scales are ordered was very different compared to my prior hospitals (think an order set with literally a hundred options)

 

[hallowmann]

As someone that very recently had a similar experience I've got to say it gets better. The hard part for me was the workload- when I moonlight I see about three times as many patients as I saw on a typical intern shift in psych. It's an adjustment but you manage, and it's a big part of your growth as a physician. Second everyone above with regard to UptoDate, Medscape, and building a good bond with staff. Much as in intern year, a good nurse can save your ass when they know patients you are just meeting for the first time. They'll tell you something is off, or if things seem fine, and can be a great compass.

Wait, what? 3x the amount of intern year? You managing 24+ pts a day??

And I feel you for the med-psych, it's partly why I chose my training, the med in psych and the psych in primary care.

 

[Mad Jack]

Wait, what? 3x the amount of intern year? You managing 24+ pts a day??

And I feel you for the med-psych, it's partly why I chose my training, the med in psych and the psych in primary care.

18 inpatients plus whatever consults and ER patients we have. Typical day is 2 consults and 4 in the ER that need evaluations and meds (many more need dispo decisions but those are charted by the BH clinician). Solo community hospital coverage, but hey, it pays well. And managing that level of work really helps you develop a strong sense of autonomy and competence.

 

[hallowmann]

18 inpatients plus whatever consults and ER patients we have. Typical day is 2 consults and 4 in the ER that need evaluations and meds (many more need dispo decisions but those are charted by the BH clinician). Solo community hospital coverage, but hey, it pays well. And managing that level of work really helps you develop a strong sense of autonomy and competence.

Yeah, that's a lot. Good money, I'm sure. Give me clinic almost any day honestly, 😄

 

[Mad Jack]

Yeah, that's a lot. Good money, I'm sure. Give me clinic almost any day honestly, 😄

I may have literally been doing napkin math over the weekend to determine when I'll never have to do this again lol

 

[PikminOC]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

Yes when it's your liability it's a different ball game

 

[FlowRate]

Yeah that's why I liked indirect supervision outpatient. I had one direct supervision clinic still my last year and it was pretty painful. I was much more in the "if I have a question I'll ask you" status at that point.

OP agree with everyone else, don't be afraid to reference sources frequently, check med interactions frequently, etc. It's actually great practice for having the complete liability as an attending.

This is what I was thinking. I generally felt like I was making all of the decisions for my patients in the moment while on call or in outpatient years. Supervision was always readily available but only required for big decisions (discharging ED consult pt w/ presenting complaint of SI for example.) We also did supervisory call in 4th year including being allowed to give the OK for some of those big decisions when it was a 3rd year calling which helped in building that comfort with responsibility.

 

[PreHippocrates]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

Just putting in my 3 cents, though others have more experience.

I'm a fellow and also moonlight, started a couple of years ago, initially at a small community hospital either doing overnights with consults/ED/ward coverage, or weekend ward or consults/ED days. More recently I started at a state-hospital level for a different moonlighting gig with no ED, no consults, no AMA discharges, and no unplanned admissions. I'd say that I would always dread my ED consults, even a couple of years into it, doing it several times per month. I never got to feeling comfortable with higher-risk discharges, even though I think my clinical thinking has been sound. [As a pro-tip, I was also a strong resident, and when feeling a little uneasy about a decision, I would think 'how would I justify this to an attending, and am I certain that this is the best way to proceed?', then I'd document the heck out of it and I always felt better getting all my thoughts out.] I don't think I delivered bad care, and I can always talk to Master's level clinicians, nurses, or ED docs about my thinking to ensure that I wasn't too far out there - and it was always reassuring.

But long-story-long, I still don't like covering the ED, I still dread those shifts. I'd gladly take 'more acute' state-hospital level patients, where there's no AMA discharges, no turf-wars with other specialties, and no trying to suss out cluster-B risk overnight with no collateral and no great temporizing disposition.

I think the moonlighting helped me to determine that I'm certainly capable of that kind of work, but it's not a great fit for me in the long run. When I no longer am needing to moonlight, you can bet I won't be stepping foot in an emergency department.

Best wishes on your fledgling independent practice.

 

[Merovinge]

Just putting in my 3 cents, though others have more experience.

I'm a fellow and also moonlight, started a couple of years ago, initially at a small community hospital either doing overnights with consults/ED/ward coverage, or weekend ward or consults/ED days. More recently I started at a state-hospital level for a different moonlighting gig with no ED, no consults, no AMA discharges, and no unplanned admissions. I'd say that I would always dread my ED consults, even a couple of years into it, doing it several times per month. I never got to feeling comfortable with higher-risk discharges, even though I think my clinical thinking has been sound. [As a pro-tip, I was also a strong resident, and when feeling a little uneasy about a decision, I would think 'how would I justify this to an attending, and am I certain that this is the best way to proceed?', then I'd document the heck out of it and I always felt better getting all my thoughts out.] I don't think I delivered bad care, and I can always talk to Master's level clinicians, nurses, or ED docs about my thinking to ensure that I wasn't too far out there - and it was always reassuring.

But long-story-long, I still don't like covering the ED, I still dread those shifts. I'd gladly take 'more acute' state-hospital level patients, where there's no AMA discharges, no turf-wars with other specialties, and no trying to suss out cluster-B risk overnight with no collateral and no great temporizing disposition.

I think the moonlighting helped me to determine that I'm certainly capable of that kind of work, but it's not a great fit for me in the long run. When I no longer am needing to moonlight, you can bet I won't be stepping foot in an emergency department.

Best wishes on your fledgling independent practice.

Absolutely, you don't find this stuff out if you don't do it. I loved C/L and ED work as a med student and as a resident. Doing it as an attending was absolute misery. I think moonlighting in different settings is a great way to figure out what system of level of care is best suited to one's individual strengths.

 

[smalltownpsych]

Just starting to moonlight and now that I'm essentially on my own, with my own decisions (and liability) to marinate in, I'm suddenly feeling very insecure all over again. By and large I've been a strong resident and have received very positive feedback through my training thus far, but now that I'm no longer within the confines of my program I feel totally inadequate. I'm guessing this is common? Anything you recommend to counteract these feelings or other bits of advice for someone just starting out on their own?

Spend time with residents who are earlier in their training. I find that when I talk to newer clinicians I realize I have a lot more knowledge and competence than I think I have. Even if I’m not quite confident in my knowledge of how to proceed at any given point, at least I know more than them!

 

[OldPsychDoc]

Find your inner "Batman". What would Batman do......

And have a personal Alfred on speed-dial who you can curbside now and then.