Good test scores, feel lost in clinic

[brownwolf100]

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Hey everyone,

So I'm curious if what I'm experiencing is normal. I've performed very well on the USMLE, preclinical course work, and my shelfs this year, but I honestly feel very lost in clinic. It takes me forever to get a picture of the patients when doing chart review, and when I go in to do my histories and physicals I always forget to ask relevant stuff and complete important parts of the physical. I tend to get bogged down in the details of the encounters and a lot of times I find myself at total loss of a plan or direction when I'm walking out of the room to talk with the attending.

I feel like I have all the knowledge expected of me, but I'm struggling to put it all together when I have to be spontaneous and in charge of the encounter. I also rely heavily on notes for presentations, because it turns out real patients have 20 more things wrong with them than the standardized patients of year 1 and 2.

Has anyone been through a similar experience before during 3rd year? When were you finally able to see a patient and feel that you were competent enough to actually offer them anything? Should I continue to try to improve everyday and trust in the system, or should I be more worried?

 

[Oso]

Sounds about right. Welcome to the real world. You will get better with time, especially in terms of skimming a chart quickly and picking up what's important, and getting the relevant stuff out of an H&P. My advice would be to ask your attending/residents for feedback and for ways you can improve. You'll get the hang of not relying on notes as much as you become more comfortable with what's going on. I would rather have you present in an organized manner, using your notes, than winging it and presenting a mess. Lastly, USMLE/testing means close to nothing in real life.

 

[Bacchus]

Agree with the above. Clinical medicine is so much more than the first two years of school. As a relatively new third year you will look back at the end of this year and be surprised how far you have come. Don’t be bothered by the chart review. As an attending it can still lead to the proverbial rabbit hole. Here’s an example: saw a patient for the first time today. Her PCP left our office. The problem list on Epic was a train wreck. It was recorded in the problem list she had a AAA but no surgical history was there such as s/p AAA repair. This led me to scanning the chart. I didn’t see a consult note regarding this and a consultant wasn’t listed in the care team. This then led me to having to access her linked CareEverywhere account to find a vascular note from a separate institution. I then had to look through the imaging to see grafting was done. I was down the rabbit hole and wasted a significant amount of time by the time I was able to get into the room. Of course I had to do this to 1) make sure she received appropriate care and 2) to cover my butt.

As far as confidence and a semblance cohesiveness go? You should notice this developing after FM, peds and Medicine rotations are over.

 

[073116]

Same here, MS3 and I think OP you just need to stick to basics, make it simple, at least until you are comfortable with it. I mean make simple thought gathering process (don't try to cover everything at once) and presentation to attending/resident, but not h&p itself.

So for example, before going to patient room, I'll glance over vitals, labs and note only abnormal ones (it's easy since they are highlighted by default in the system), CXR/scans and EKG - only summary and impressions (so you don't need to read everything) and admitting physicians note for HPI and diagnosis (if available) not to copy/past it, but to know on what system I should focus more during my patient encounter and h&p.

After I see patient, I take 2 min to review my h&p and I only present c/c, PMH and pertinent symptoms (from ROS) followed by positive PE findings and most probable differential. If it's a ED case - I also include code status and vitals. Everything else I only mention if attending/resident ask for specifically.

As it was mentioned above - it just takes time and practice. We'll all be more efficient by the end of 3rd year.

 

[831929]

hmm maybe you just didnt perform as well as you think on step and shelf exams?

just kidding lol yeah that is how most people feel all day

 

[Onigiri]

Feeling the same way! One thing that helped for me was memorizing bread and butter differential diagnoses for chest pain cough, and stuff like that, so before I see the patient I can have a plan, and when I see the patient, I can ask questions tailored to r/o stuff. and assessment and plan will be better!

I am decent at tests, but when trying to think outside the box clinically all the different variables that go into pt management I seem to not get it right. I realized that, maybe I can't think outside the box, but if I keep learning, I'll remember those things outside of the box and bring them inside where I am most comfortable.

 

[BigRedBeta]

As others have said, there's a sequence to the whole thing.

It is also very common for students at your stage to feel like "if I could just see diagnosis X, then I'll know what to do the next time". Unfortunately, as you may be realizing, even if you were superstar student who memorized the top 100 diagnoses for every rotation and their workups/treatments, you'd be SOL when diagnosis #107 walks through the door. There's also a huge tendency to focus on etiology as if pneumonia from strep pneumo is somehow completely different than pneumonia caused by klebsiella.

I've found it helpful (and had trainees under me say the same thing) to realize that symptoms are usually a final common pathway of dozens of different causes, because in large swaths, the physiology and the response mechanisms progress in the same way. This allows you to think of your treatments more like tools in your toolbox, and you can use them in a variety of different problems across multiple clerkships. It also gives you a starting point to think about how youre going to support your patient until you can figure out more of the details.

 

[hmockingbird]

Yep this is normal.

One thing that helped me in med school was if I had a CC to go off of I’d quickly write down (or look up!) a differential. This will help you start to figure out what questions to ask. If all else fails do a thorough ROS.

As for chart review, that will also come with time. I’d say if there is imaging always look at it yourself. 99% of the time the read is correct but this will help you learn imaging (and IME attendings often ask students/interns if they looked at it and if they could read it for the team so you’ll want a preview).

 

[SLC]

OP, don’t sweat it. At this point in your education you’ve not yet been trained to filter; what do I mean by “filter”, it’s a skill that comes with experience where you sorta “latch on” to the stuff that’s important in a patient encounter and not the extraneous detail that a patient will insist on telling you. It also starts to inform your patient interviews and exams, and makes presenting much more simple and effective.

It comes in time, don’t worry.