Halfway through intern year...

[beefbroccoli]

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Hi, I hope other interns and senior residents and attendings can weigh in on this...👍

I'm halfway through my intern year and (granted, I have been on almost all off service months for the first half of this year, only had about 15 real ED shifts..) ... I feel my clinical knowledge is awful and I have no clinical gestalt. Like when the abdominal pain patient comes in, unless it's flagrantly obvious it's surgical or the patient is in extremis, I'm still so bad at telling if something bad requiring admission or just gastroenteritis. Our attendings keep telling us that we should start acting like an upper soon but I feel like the gap between even the second years and me is this HUGE gaping chasm.

I try to keep up with reading as best as I can and I'm doing well on our weekly quizzes and I try to look up at least three new things I learned on each shift, but honestly I am disheartened that half the year is over and I still feel very not confident about anything.

Any tips on how to improve clinical knowledge, efficiency, and confidence in the ED? Thanks 🙂

 

[EM2BE]

More time in the ED. Abd pain is not simple. If it were, you wouldn't have a large enough differential. It will get better. I used to think the same exact thing one year ago (half way through my intern year). It will get better with time.

 

[jendc08]

You wil get better with more time. As you said, you have only had 15 ED shifts so far. Don't panic.

 

[gman33]

I'm still a know nothing MS4, but I wouldn't worry about it yet.
You've only worked about 2 weeks in the ED.
You shouldn't expect too much of yourself.

It's probably good that you feel unsure of your knowledge,
It means you are thinking carefully about your patients and are working hard to improve your skills.

I'd be be worried if you said you felt totally comfortable.

 

[tkim]

dude, belly pain is tough. it's one of those things that after you do an appropriate workup +/- imaging, you may not figure out, and dispo home with 'abd pain - unspecified' - especially in the 18-45 y/o F population ...

don't sweat it.

 

[wobit]

I'm also halfway through my intern year and if anything I'm slower and less certain now than I was at the beginning. I've also had nearly all off-service months and no chance to integrate the knowledge, just more and more exposure to people talking about that one the time the ED got it wrong. Once I'm back home in the department and spending more time with my mentors, it'll get better. I've developed some great technical skills and learned how to communicate with those other services, so I feel like it's been 6 months well-spent. It just hasn't come home to roost yet.

 

[EM4life]

I'm a third year. I can tell you that it will certainly get better, and at some point it will start to click and you do have to trust it will. It's hard as an intern because you have not had enough experience yet so one bad day really kills you (at least it did for me). I felt like if one shift didn't go well, I'd question my clinical judgement or gestalt. Trust me, sometime towards the end of this year, and especially when your new interns show up, you will realize how much you have learned. You will learn that there are patients who absolutely need to be admitted no matter what their workup shows and there are patients who can go home without you doing anything. Everything in the middle, that gray area where you don't know what will happen to them, that gray area will get smaller and smaller the more you work and see more patients. Hang in there!

 

[beefbroccoli]

Thanks for the advice, insight, and encouragement, everyone! I really really hope it gets better.

And EM4Life, what you said about how one bad shift can kill you definitely rings true for me. I have had some great shifts and other terrible shifts where I can't do anything right and then I go home and feel extra ******ed I missed something or didn't consider a diagnosis etc etc.

Thanks everyone 🙂

 

[Hamhock]

Here's another slightly-more-senior opinion (young attending):

Don't worry about it. Most likely you're doing just fine and are appropriately concerned. Try not to worry about it and continue to work hard.

However, if you have some objective evidence of being behind your peers - which you haven't reported...and may not be that important at such an early stage - or have a history of being middle of the pack or less, I wouldn't worry.

You'll laugh in a few years...until you get similar feelings as a young attending!

HH

 

[EM4life]

Haha no doubt I will feel the same way again this July!

 

[WilcoWorld]

You wont feel smart until there's a new crop of interns around to show you how dumb you used to be.

 

[Daiphon]

You wont feel smart until there's a new crop of interns around to show you how dumb you used to be.

There's nothing better than a comparator...

To the OP, you should occasionally feel overwhelmed; that's how you figure out what you need to work on... Plus, being primarily off-service to this point somewhat dulls your ED skills. They'll get better, I promise. Work hard, read your butt off, and always put the patient's interests first. Everything else falls out from there.

Cheers!
-d

 

[Cerberus]

Agree with what others have said. It will come so long as you are working hard to learn the medicine. Read more. Listen to EMRAP. Listen to your attendings and consultants and then fact check what they just told you. I remember being midway through intern year and thinking about how much I did not know, and how weak I was in certain areas - that's normal and it's good that you realize it. I'm done with most of my EM months of second year and there is still a lot I don't know, but there is a hell of a lot less of it than 1 year ago and I feel confident with managing 90+% of what I see in the ER.

 

[beefbroccoli]

Thanks for all the replies you guys-- Y'all are so encouraging! 😍 I am at a high volume place (>130k a year) so hopefully I will see a ton and start to feel comfortable with pattern recognition.

I do feel some improvement on each shift so that is encouraging but last night I saw a 50 yr old patient with pmh DM and no family hx who I totally thought had gastro (labs totally nml) until she didn't improve with GI cocktail so we decided to scan and then CT showed hemoperitoneum :O. Abdominal pain still scares the crap out of me. I saw like 5 abdominal pain patients last night almost all with the same symptoms (n,v,d, crampy lower abd pain) and 2 had gastro, 1 had sbo, 1 had a pancreatic nodule and mesenteric adenitis, and the 1 with hemoperitoneum.

Argh. So frustrating. But now I truly understand the importance of serial abdominal exams and reassessment!!

 

[pinipig523]

Read the GI chapter in Tintinalli... know that you are still an intern and you will get better over time.

Take initiative and you'll do fine.

 

[Rendar5]

Hemoperitoneum? What did the guy have that caused that?!

Anyway don't feel bad. Abd pain is a tricky one, and if in treating it, something doesn't add up, go the next step and image. Be extra vigilant in the elderly patient, the RLQ pain, the repeat offender, and the peritoneal patient.

One night intern year, I had 5 AGE cases all exactly the same with a nonfocal moderately tender belly, but no rebound, +vomiting, diarrhea, subj. fevers.. 4 got better within 1-2 hours of fluid +/- opiate + zofran, 1 kept puking and had increased pain, so he got a CT. Nothing particularly special about it. He didn't have any rebound until AFTER the CT revealed his appy. Seen plenty of abd pain since then that fooled me on my first look, but that's why you re-eval.

 

[VienneseWaltz]

Thanks for all the replies you guys-- Y'all are so encouraging! 😍 I am at a high volume place (>130k a year) so hopefully I will see a ton and start to feel comfortable with pattern recognition.

I do feel some improvement on each shift so that is encouraging but last night I saw a 50 yr old patient with pmh DM and no family hx who I totally thought had gastro (labs totally nml) until she didn't improve with GI cocktail so we decided to scan and then CT showed hemoperitoneum :O. Abdominal pain still scares the crap out of me. I saw like 5 abdominal pain patients last night almost all with the same symptoms (n,v,d, crampy lower abd pain) and 2 had gastro, 1 had sbo, 1 had a pancreatic nodule and mesenteric adenitis, and the 1 with hemoperitoneum.

Argh. So frustrating. But now I truly understand the importance of serial abdominal exams and reassessment!!

You are wise to be worried about abdominal pain--it's extremely challenging to diagnose by clinical assessment alone. DM + abd pain is even trickier.

Abdominal pain is my least favorite CC. I would rather take 5 vag bleeders + 2 lower back pains than deal with a nonspecific bellyache.

But to echo the others, you will get better the more you see, and when the new interns arrive you will be astonished at not only the knowledge you've gained but the confidence you didn't realize you had.

 

[SoCuteMD]

La Bella Vita - it's January of intern year. This is the low point. It gets better soon, I swear! You may not feel like you are learning, but you are. Come July, when the new interns start you will watch them learning to be doctors and realize exactly how far you've come. You are right to be nervous about abdominal pain. It's a tricky chief complaint and the diagnoses behind range from completely benign to imminently life-threatening and everything in between.

 

[Khaos]

I remember in my third year being asked about moonlighting from the first and second years that were thinking about it. They would ask me all about trauma, critically ill patients, etc...I explained to them I was never concerned about those when moonlighting because those were easy. You intubated, put lines everywhere and shipped them to the nearest place that actually handled those kind of patients. I explained to them the ones that always made me worried were the little old ladies that came in with vague abdominal pain. These are the ones that could die and never really tell you what was wrong. The differential is huge. I always hated sending home the little old 80 year old male/female that had not been in an ED in their entire life and labs, urine, cxr, CT abd with contrast are all normal.

A great example is a patient I had the other day. Gentlemen in his late 60's with diffuse abd pain. No specific spot but started 2 days prior. Exam did not have surgical abd, just diffuse pain. Labs, ekg, urine, ct abd w/contrast nothing acute. Discharged home. Came back 2 nights later saying the pain moved and is now staying in his RUQ. Labs this time showed a bump in liver enzymes and gallbladder inflammed with fluid around it.

 

[beefbroccoli]

Thanks for all the replies and insights, everyone!! I enjoy reading everything that is being said on this thread.

@ Rendar5, she bled 3L from her superior pancreaticoduodenal artery...! No idea how or why that happened... the good news is that she did well after her exlap. But yeah, I'm now hypervigilant in abd pain, esp in old people or diabetics.

Kids are absolutely destroying me too. Yesterday I swear I saw 15 cases of the same thing, vomiting diarrhea fever. They all had the same physical exam too, more or less. Except my attending picked one kid out of the mix and told me, "I think this kid has appendicitis. Let's scan him." (I went and examined this kid with the attending too and nice soft belly no rebound no guarding suprapubic tenderness could jump up and down.) And he had freaking appendicitis. Argh. D: D: D:

Clinical gestalt, I pine for thee.

(I also recently saw a pregnant lady 1st trimester with vomiting and epigastric pain... GI cocktail improved s/sx, ultrasound negative for chole, d/c-ed home... then came back with appendicitis. FML.)

 

[blackavar]

Thanks for all the replies and insights, everyone!! I enjoy reading everything that is being said on this thread.

@ Rendar5, she bled 3L from her superior pancreaticoduodenal artery...! No idea how or why that happened... the good news is that she did well after her exlap. But yeah, I'm now hypervigilant in abd pain, esp in old people or diabetics.

Kids are absolutely destroying me too. Yesterday I swear I saw 15 cases of the same thing, vomiting diarrhea fever. They all had the same physical exam too, more or less. Except my attending picked one kid out of the mix and told me, "I think this kid has appendicitis. Let's scan him." (I went and examined this kid with the attending too and nice soft belly no rebound no guarding suprapubic tenderness could jump up and down.) And he had freaking appendicitis. Argh. D: D: D:

Clinical gestalt, I pine for thee.

(I also recently saw a pregnant lady 1st trimester with vomiting and epigastric pain... GI cocktail improved s/sx, ultrasound negative for chole, d/c-ed home... then came back with appendicitis. FML.)

right there with you...when people ask me how intern year is going, the thought that crosses my mind is, there are too many days where I feel that patients get better inspite of me, not because of me...but I do think it will get better...just keep treating, just keep treating, just keep treating (think finding nemo)