Graduating residency....and really struggling

[BiscoDisco]

I need some help guys. Today is my final day of residency. I've been moonlighting quite a bit over this last year, so I have gotten some "real world" experience under my belt. But I can't shake this awful feeling that I am woefully underprepared. I could have definitely read more during residency, I could have tried harder. I feel as though I skated by on my outgoing demeanor and good personality. I got stellar reviews in residency, but I genuinely feel like I've duped people.

I still find myself looking up basic things. I still find myself not knowing basic things. Like, what are all the labs/tests I should check before starting clozapine? Yeah I would need to look this up right now. I feel as though medico-legally, I still have no clue what I'm doing with regards to things like, how to terminate a patient, how to deal with a patient who isn't paying their bills, etc things like that. I do feel like I have the ability to write a good note/suicide assessment so I have that going for me.

But otherwise, I just feel completely lost and overwhelmed and I havent even started work yet (this begins in August). To be honest, I feel like a complete fraud. I am starting with a therapist to help me work on some issues, but I'm just scared and really down righ now. Any feedback would be helpful.

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[smalltownpsych]

I always prefer working with newer clinicians that lean toward too much doubt than leaning toward too much confidence. The first will ease up with experience, the second will get worse with experience!
Part of why I chose the field of psychology is that we are at such a basic stage of knowledge that I knew that I would never get bored, but the flip side of that is that human behavior, cognitive processes, and emotional states and the bio-psycho-social determinates of that are incredibly complex interactive systems that challenge all of our abilities every day. As your brain is trying to grok all of this and treat the patient in front of you, it can be very hard to remember the details such as the technical medical part of it. It has to do with cognitive shifts as it is different types of processing and that takes effort.
For me an example of the current shifts are from providing emotional support and crisis intervention to making sure that administrative tasks of running a business are being done. Part of what makes a good psychiatrist and psychologist , in my opinion, is the ability to shift and integrate these cognitive paradigms or states of mental functioning.

 

[FlowRate]

I still find myself looking up basic things. I still find myself not knowing basic things. Like, what are all the labs/tests I should check before starting clozapine? Yeah I would need to look this up right now. I feel as though medico-legally, I still have no clue what I'm doing with regards to things like, how to terminate a patient, how to deal with a patient who isn't paying their bills, etc things like that. I do feel like I have the ability to write a good note/suicide assessment so I have that going for me.

If you're not prescribing clozapine on a regular basis, this is normal.

If never had to terminate or address payment issues with patients during residency, or only had to do so once or twice, this is normal. Especially since there is a range of reasonable opinions on exactly how to go about doing so.

In what sort of practice setting will you be working? Will you have colleagues?

 

[annoyedpsychiatrist]

Being a resident is a learning process, but so is being an attending. Ive read and read and read some more and yet I still learn more as I go along. Tidbits here and there. I forget stuff as well. Its part of it really. You will never have all the answers as an attending and you will have cases where sometimes you get stuck for a bit.

You will grow more and more as an attending. Its ok to have doubt and fear. These two things encouraged me to grow, read, and learn and improve. If i was overly confident I wouldnt have sought out bettering myself. Ive been an attending for two years and the learning never stops. Heck im learning that some stuff i was taught in residency wasnt exactly the right way of doing it.

 

[BiscoDisco]

If you're not prescribing clozapine on a regular basis, this is normal.

If never had to terminate or address payment issues with patients during residency, or only had to do so once or twice, this is normal. Especially since there is a range of reasonable opinions on exactly how to go about doing so.

In what sort of practice setting will you be working? Will you have colleagues?

I will be inpatient and in the ER and have colleagues I can talk with there of course. I will also be working outpatient in my own clinic, I can always consult residency classmates.

 

[Celexa]

As a doctor, you are always, always learning. It would be more concerning if you thought you knew everything and were fully formed as a clinician after residency. There are doctors like that and they are not good doctors.

Engaging with a therapist is a good idea if the anxiety of being in independent practice is overwhelming. At the same time, looking things up, asking colleagues for input, and having humility about the vast breadth of what you don't know are good things.

 

[tr]

Starting as a new attending is scary no doubt, but you sound way too concerned about very normal and unremarkable stuff.

What's wrong with looking stuff up? I would definitely have to go look up the baseline labs if I were going to start someone on clozapine (haven't done that in many years). I start lithium pretty regularly and I still double check myself to make sure I didn't forget to order anything.

The procedural/business stuff, you'll figure it out as you go along. Ask other people what they do when stuff comes up.

Also, try to let go of the impostor syndrome. You sound fine to me. It would be more worrisome if you were overly self-confident.

 

[annoyedpsychiatrist]

the most annoying part of prescribing clozapine isnt necessarily the med, its the ensuring people get required weekly labs and reporting to REMs. It was more stress to me wondering if i was going to have to start from scratch and patient decompensates due to not getting required ANC. If off more than 48 hours you have to retitrate, although you can go faster depending on how long youve been off. If you do not have a lab inhouse or easy way to get labs then I wouldnt recommend utilizing clozapine frequently or at all. Even if the lab is a mile down the road, it may as well be on the moon. Heck we had a lab onsite and it was still a struggle. Its really more ideal for facilities that have services like case managers.

in psychiatry youre not expected to fix everyone, youre only expected to be polite and do your best. you can not help everyone. You cant be any worse than some of the providers ive seen. I have patients come to me all the time, on antipsychotics years and I do an AIMs and they have no idea what that is/have never done anything like it in the past. Just dont overprescribe or try to rush treatment. Slow and steady wins the race in the outpatient setting. Focus on whats working/whats not working. Use logic to come up with plans. Set expectations. Be transparent.

 

[wolfvgang22]

Yeah, I'm the "clozapine doctor" in my area now, but when I started out I had to look up everything. I'm also the suboxone guy, learned how to do MAT for opioid use disorder the same way, lol. You'll be fine!

 

[comp1]

First and foremost, your reaction is normal. Therapy is great. Hopefully it will re-enforce the normality and universality of your experience. You're graduating residency, so it appears at least some educated people thought you weren't completely fraudulent.

 

[clausewitz2]

First and foremost, your reaction is normal. Therapy is great. Hopefully it will re-enforce the normality and universality of your experience. You're graduating residency, so it appears at least some educated people thought you weren't completely fraudulent.

When you start feeling like an impostor, this is a good thing to think about. Your program graduated you, suggesting they thought you were competent enough to be an attending.

Do you think they were stupid, crooked, or gullible?

Either they're very bad at determining who and who is not ready to practice, they lied about it for nefarious reasons, or you successfully conned the whole program for years. Not really another way out of it.

If you don't think any of those apply, may be food for thought.

EDIT: Remember when you were on your first inpatient rotation as a resident and you looked up appropriate dosing for tylenol? Yeah, being a fresh attending is like that, just at a higher level. We all been there.

 

[Bartelby]

A few thoughts:
1- this sounds like imposter syndrome. It is very common, and it does not mean you are actually incompetent. I would trust the reviews you have received from experienced attendings more than your own intuition about your level of skill.

2- as others have pointed out, looking things up is not a bad thing at all. I have been out of training for more than 5 years and I still regularly look things up, including things I do frequently if I have not looked it up in a few months. Even if you have a perfect memory (which I don't), standards of practice will evolve over the years. Keep in mind as an attending you are not taking an exam, there are no bonus points for refusing to look things up.

3- there is a learning curve for new attending practice. This is the case even if you are well out of training. For example, having 10 years of running your own outpatient clinic will not necessarily mean that you can start an inpatient role and function as if you had many years of inpatient experience. The good news is that you get up to speed pretty quickly. It usually takes a few months, but after a few months you have encountered most of the tricky situations you are going to run into and they are much easier the second time around.

4- It is easy to freak yourself out by imagining all the most difficult situations you could possibly encounter and then catastrophizing about how you would be unable to handle them. Over the years you will realize that most of what you end up dealing with is routine and is pretty straightforward. When more complicated things come up, it generally ends up being pretty easy to figure it out. No training can ever expose you to every possible situation you will encounter over the course of your practice, but your training prepares you very well to figure out new situations as they arise.

 

[splik]

you still have a lot of learning to do. You will learn a lot in your first yr as an attending. It’s different when the buck stops with you.

No one knows it all and you will develop the skills you need as you go along. Residency gives you a good background.
There were several things I learned in my first years as an attending I didn't during residency and fellowship including: transplant evals, donor evals, epilespy surgery evals, managing factitious disorder (which I'm now considered an expert but I only saw a few cases in training), amytal interviewing, insanity evals (didn't do any in forensic fellowship), sex offender risk assessment, treating non-epileptic seizures. I also trained in MBT, ACT, and schema therapy which I didn't learn in residency.

This past yr I've gone into private practice and it has also been a steep learning curve!

Residency has given you a basic foundation on which you will continue to develop.

Also, in addition to informal and formal mentorship, you can get supervision and/or case consultation (you'll have to pay now you're out of residency) to continue to grow and develop your skills. Some people think this is just for therapy, but I provide supervision and case consultation on a range of different areas that fall under my particular expertise. You won't have all the answers. I consider myself pretty experienced and knowledgable but I still consult with colleagues and friends for challenging issues that come up in my practice. I've also been fortunate to be able to consult with my past attendings when I've needed to. It is good practice to do so and also helps show you are following the standard of care in the event of a lawsuit.

 

[Sushirolls]

Normal.
3-9 months you should be like feeling a bit more at ease and less imposter.

Just wait, it will morph in 7-12 years, you might start thinking, am I now that outdated doctor who prescribes Buspar for everything?

 

[Candidate2017]

One of the main purposes of residency is to teach you how to be... a good resident. Play well with others, don't whine too much, be teachable, take tests, don't kill patients, make attendings' lives easier. Billing and practice management, which are large parts of being a physician, isn't really part of residency unless you take it upon yourself as a PGY-3 and 4. Knowing your worth, negotiating fair pay, and standing up for yourself? Those things definitely aren't part of residency training and are actively discouraged. Long story short, you don't really learn how to be an attending in residency. You learn how to be an attending in attendinghood.

BTW it's ok to look things up, as well as consult with peers. This differentiates us from midlevels and other assorted cowboys.

Just wait, it will morph in 7-12 years, you might start thinking, am I now that outdated doctor who prescribes Buspar benzos for everything?

 

[Dharma]

Keep asking questions, keep reading, stay curious. What you're feeling is fairly standard. I worry more about the graduate who is too cocky fresh out the gates. You'll be fine.

 

[Stagg737]

Agree with everything said above. Cut yourself some slack, in all likelihood you are fine. Residency should teach you to be clinically competent and knowing what you don't know is a great prognostic sign for your career.

I feel as though medico-legally, I still have no clue what I'm doing with regards to things like, how to terminate a patient, how to deal with a patient who isn't paying their bills, etc things like that.

Residencies should teach this, but most don't. I've talked to no one who got a strong education from their residency on the administrative/financial side of practice and the best thing my program did for us was have a didactic session with 3 people who had graduated when I was a PGY-1/2 who talked to us about their practices in my PGY-4 year, what they had to learn, and how they adjusted. Medico-legal can be tricky and I think my education there was a bit above average d/t a particular feature of my program that is pretty rare (won't go into it here d/t possible doxxing, but can discuss if really interested), but as long as you're aware of the basics to not get sued/lose your license you should be fine.

But otherwise, I just feel completely lost and overwhelmed and I havent even started work yet (this begins in August). To be honest, I feel like a complete fraud. I am starting with a therapist to help me work on some issues, but I'm just scared and really down righ now. Any feedback would be helpful.

Another vote for the bolded is totally normal and probably a good thing. My first day as an attending I saw my ER patients and started looking for the person to staff with for about 30 seconds before I realized that was me, lol.

 

[Merovinge]

I need some help guys.

The fact that you started a post with that as the first sentence makes you instantly hirable to me. Anyone who can get through all of medicine where overconfidence is one of the most rewarded traits (both by peers, admin, AND patients), have strong social skills, and still have the humility to ask for help is going to do great in psychiatry. Come back to this post in a year and let us know how its going, Ill take the bet on pretty good, learned a lot, ready to make the next step in my career.

 

[G Sheb]

I am actually smelling burnout and 'catastrophic thinking'.
This is very common as you get to the end of residency.
You may just need a break.

 

[Coupd'Cat]

My friend, I'm a year out and still looking stuff up on the regular. God made corkboard for a reason--so you can pin in all the flowcharts and clozapine guidelines you'd like to it. Hopefully you'll have helpful support in therapists, nurses. Unless you're going into solo practice straight out, you'll likely have a medical director to tell you how the clinic handles the admin issues you mentioned.

 

[MacDonaldTriad]

I don't know twice as much as I did when I finished training, it is more like three or four times as much. Most recent graduates are not very competent at some difficult cases. The trick is to surround yourself among talented mentors, or develop good life long learning skills. Either way, don't work so hard that you become isolated and ridiculously idiosyncratic in your practice habits. Slow and steady wins the race and you just have to move forward and not stand still. There are many many poor psychiatrists out there. If you don't want to be one, good for you. As said above, your anxiety makes us think you will be fine. Overconfidence is much worse than a lack of confidence and if you can channel your lack of confidence dysphoria into action, you will kick tail and be great.

 

[annoyedpsychiatrist]

My friend, I'm a year out and still looking stuff up on the regular. God made corkboard for a reason--so you can pin in all the flowcharts and clozapine guidelines you'd like to it. Hopefully you'll have helpful support in therapists, nurses. Unless you're going into solo practice straight out, you'll likely have a medical director to tell you how the clinic handles the admin issues you mentioned.

to add to this im two years out myself. After one year i feel my knowledge increased substantially, and after two years i feel like it only continued to grow. Being independent forces you to learn, its a lot easier being more complacent in residency, but knowning people depend more on you as an attending, is often incentive to learn/grow.

 

[smalltownpsych]

So a nurse practitioner who did some of their training with an NP I worked with graduated sIx months ago and is comfortable working with all my clients who are some of the most complex and challenging cases and is so confident with his competence at this stage that he is doing telehealth and planning to see my patients in addition to his other full time job. I mean, really, how hard is it? What is ironic is that several local psychiatrists turned down these clients because they won’t work with Bipolar or Schizophrenia.

 

[MacDonaldTriad]

So a nurse practitioner who did some of their training with an NP I worked with graduated sIx months ago and is comfortable working with all my clients who are some of the most complex and challenging cases and is so confident with his competence at this stage that he is doing telehealth and planning to see my patients in addition to his other full time job. I mean, really, how hard is it? What is ironic is that several local psychiatrists turned down these clients because they won’t work with Bipolar or Schizophrenia.

This is very scary.

 

[vanfanal]

I need some help guys. Today is my final day of residency. I've been moonlighting quite a bit over this last year, so I have gotten some "real world" experience under my belt. But I can't shake this awful feeling that I am woefully underprepared. I could have definitely read more during residency, I could have tried harder. I feel as though I skated by on my outgoing demeanor and good personality. I got stellar reviews in residency, but I genuinely feel like I've duped people.

I still find myself looking up basic things. I still find myself not knowing basic things. Like, what are all the labs/tests I should check before starting clozapine? Yeah I would need to look this up right now. I feel as though medico-legally, I still have no clue what I'm doing with regards to things like, how to terminate a patient, how to deal with a patient who isn't paying their bills, etc things like that. I do feel like I have the ability to write a good note/suicide assessment so I have that going for me.

But otherwise, I just feel completely lost and overwhelmed and I havent even started work yet (this begins in August). To be honest, I feel like a complete fraud. I am starting with a therapist to help me work on some issues, but I'm just scared and really down righ now. Any feedback would be helpful.

Seems like everyone has given you good advice. I’m 2 years out and still reference things. I was so unsure that I came to SDN to ask when to prescribe SSRIs 😂.

Wanted to share this golden quote with you…you’re in good company.

The problem with the world is that the intelligent people are full of doubts, while the stupid ones are full of confidence.

Charles Bukowski

 

[vanfanal]

So a nurse practitioner who did some of their training with an NP I worked with graduated sIx months ago and is comfortable working with all my clients who are some of the most complex and challenging cases and is so confident with his competence at this stage that he is doing telehealth and planning to see my patients in addition to his other full time job. I mean, really, how hard is it? What is ironic is that several local psychiatrists turned down these clients because they won’t work with Bipolar or Schizophrenia.