Help..end of M3 year and still struggling...

[mangos3]

I just started inpatient Internal Medicine last week in the PCCU and feel like I'm in way over my head...is this normal? This is the last rotation of my M3 year and I almost feel like I'm struggling progressively more in comparison with other M3 students as the year has gone on. I don't know if it's from sheer exhaustion that I can't seem to think clearly and struggle to follow what's going on when discussing patients during rounds or what. I still haven't figured out a good system for studying--sometimes it feels like I do the same on shelf exams whether I study much or hardly at all. It's so frustrating. I just feel lost. I can't stay awake during any meeting or presentation that lasts for more than 20 minutes. I feel incredibly inefficient...it takes me nearly an hour to see a patient in the morning right now, look at labs and come up with an assessment and plan to write up my progress note. Granted, my patients are rather complicated with problem lists that are 10 items long, but still...I feel like everyone knows more than I do and I continually feel lost. I don't know what to do at this point. I don't think I'm stupid, but I don't understand why everyone else seems to know what's going on and I don't. I just finished a month of outpatient IM and my preceptor said I was one of the best students he's ever had. I had no problem learning the material during M1 and M2 years and got Honors and HP in pretty much every class even though I had a lot of personal issues going on at the time. I have tried asking for help and feedback this year, but all I get is generic advice that really is ultimately not all that helpful (i.e. try to read up on your patients every day, follow up on things that need to be done, admit it when you don't know something...etc etc). I have trouble figuring out HOW best to study and WHAT to study..there's so many resources to choose from. Lately, I've been getting up around 4am and getting home around 7pm just trying to get everything done. I feel like I'm so worn out and overwhelmed, it's hard to study and absorb anything. I think the structure of this whole year has just been very different from how I'm used to learning that I can't seem to adjust to it. I'm used to having a very structured learning environment and knowing exactly what I need to do. I also like to study very systematically, go at my own pace and then be able to review all the material a second time after the first run through before I feel familiar with it. I'm also very much a visual learner--it's very hard for me to absorb and retain information that is just spoken to me. All of this which is completely against how M3 year is structured. I've tried to adjust accordingly, but I feel like I never found the groove. All my learning just feels very haphazard and hit or miss that I feel like I'm just guessing my way through everything.

My M3 year grades so far have been HP's in everything except a couple Passes in Peds and Ob. I really want to honor Medicine since it's the specialty I'd like to go into.

Anyways, sorry for the incredibly long and somewhat incoherent rant. I don't know if anyone can offer any sort of advice or reassurance from all that. If you can, very specific advice on definite steps of action would be more helpful than generic advice. Thanks....

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[WashMe]

I just started inpatient Internal Medicine last week in the PCCU and feel like I'm in way over my head...is this normal? This is the last rotation of my M3 year and I almost feel like I'm struggling progressively more in comparison with other M3 students as the year has gone on. I don't know if it's from sheer exhaustion that I can't seem to think clearly and struggle to follow what's going on when discussing patients during rounds or what. I still haven't figured out a good system for studying--sometimes it feels like I do the same on shelf exams whether I study much or hardly at all. It's so frustrating. I just feel lost. I can't stay awake during any meeting or presentation that lasts for more than 20 minutes. I feel incredibly inefficient...it takes me nearly an hour to see a patient in the morning right now, look at labs and come up with an assessment and plan to write up my progress note. Granted, my patients are rather complicated with problem lists that are 10 items long, but still...I feel like everyone knows more than I do and I continually feel lost. I don't know what to do at this point. I don't think I'm stupid, but I don't understand why everyone else seems to know what's going on and I don't. I just finished a month of outpatient IM and my preceptor said I was one of the best students he's ever had. I had no problem learning the material during M1 and M2 years and got Honors and HP in pretty much every class even though I had a lot of personal issues going on at the time. I have tried asking for help and feedback this year, but all I get is generic advice that really is ultimately not all that helpful (i.e. try to read up on your patients every day, follow up on things that need to be done, admit it when you don't know something...etc etc). I have trouble figuring out HOW best to study and WHAT to study..there's so many resources to choose from. Lately, I've been getting up around 4am and getting home around 7pm just trying to get everything done. I feel like I'm so worn out and overwhelmed, it's hard to study and absorb anything. I think the structure of this whole year has just been very different from how I'm used to learning that I can't seem to adjust to it. I'm used to having a very structured learning environment and knowing exactly what I need to do. I also like to study very systematically, go at my own pace and then be able to review all the material a second time after the first run through before I feel familiar with it. I'm also very much a visual learner--it's very hard for me to absorb and retain information that is just spoken to me. All of this which is completely against how M3 year is structured. I've tried to adjust accordingly, but I feel like I never found the groove. All my learning just feels very haphazard and hit or miss that I feel like I'm just guessing my way through everything.

My M3 year grades so far have been HP's in everything except a couple Passes in Peds and Ob. I really want to honor Medicine since it's the specialty I'd like to go into.

Anyways, sorry for the incredibly long and somewhat incoherent rant. I don't know if anyone can offer any sort of advice or reassurance from all that. If you can, very specific advice on definite steps of action would be more helpful than generic advice. Thanks....

It sounds like you THINK you're doing much worse than you actually are... I just finished MS2 so I can't help much when it comes to your medicine rotation, but I'll bet you're in a similar place as the majority of your class. You ever heard of "upward comparison"? It's when you only compare yourself to people who are better than you (and there ALWAYS will be someone better than you at any given skill). You should compare yourself to the low man on the totem pole sometimes, just to see that you may be "average" but you're probably not drowing. Hang in there!

 

[desijigga]

If you are in the CCU ya it will be tough as a 3rd year (heck even residents have a hard time). I understand complicated patients take time, but one hour is just too long. Try to trim it down 5 minutes every week, ideally a new H and P should be done in 35-40 minutes by a student. 20 minutes going through all the EMR, reading up on pt, and 15-20 minutes PE and history taking.

You said you just started, it takes time to adjust. You seem like a hard worker, just work at it. Only expectation they have from students is doing through H&Ps, presenting in a reasonable manner, and trying to formulate an assessment and plan, answer questions here and there. Anything beyond that and your at the level of intern.

I am sure there are willing residents to help you, I had this one fellow on ID that really helped me with my presentations. My IM attending made me efficient at doing physicals and taking a quick thorough history. I had this one card fellow who would grill the crap out of me till I understood a concept. Ask for help, if a person is busy move on to the next member of your team.

 

[Perrotfish]

I can't stay awake during any meeting or presentation that lasts for more than 20 minutes.

...

Lately, I've been getting up around 4am and getting home around 7pm just trying to get everything done.

I feel like the above sentence are sort of key. You're running on fumes and it's causing depression and inefficiency. If you're struggling to stay conscious you're not going to be efficient.

I don't have any advice on how to honor, considering I never f-ing honor anything. However I can reassure you that everyone feels lost and miserable when they're low on sleep. FWIW I think it might be worth it to take your next day off and spend it relaxing and sleeping. What you lose in study time I think you might gain back in efficiency, especially if you can start working on a more normal sleep schedule going forward.

 

[mangos3]

Thanks for the replies. I really appreciate it. I had a nice cry about about it yesterday after posting (very much needed) and am feeling a bit better today. It turns out that the team I was on was very much a factor in my feeling overwhelmed--it was the residents' last week on the service, 2 of them were graduating from residency in a month and were pretty much checked out already, and I was working with another MS3 who had already been rotating for a month before me. I just started with a new team of residents and attending who have a much more structured system and are making a good effort to include students in the discussions and incorporate teaching. I think it will be MUCH better going forward.

My biggest thing now is that I still feel that my knowledge base is deficient and I don't have a good method for studying. Does anyone have a learning style similar to mine (systematic, like to take my time to understand thoroughly, never really used questions to study during M1/M2 years--just read the text one time VERY thoroughly through, then massive review of all material second run through a few days before the test)? How did you adapt to studying M3 year? (especially for the volume of information covered in Medicine.) Or even if you don't, I would still appreciate SPECIFIC suggestions on how to study that have worked well for you that you think would help. e.g. what exactly does "reading up on your patient" entail? What resources do you use? How do you balance between studying overall content for the shelf exam with studying for miscellaneous topics for the wards, TBL quizzes, and the like?

Thanks again!!

 

[JustPlainBill]

Thanks for the replies. I really appreciate it. I had a nice cry about about it yesterday after posting (very much needed) and am feeling a bit better today. It turns out that the team I was on was very much a factor in my feeling overwhelmed--it was the residents' last week on the service, 2 of them were graduating from residency in a month and were pretty much checked out already, and I was working with another MS3 who had already been rotating for a month before me. I just started with a new team of residents and attending who have a much more structured system and are making a good effort to include students in the discussions and incorporate teaching. I think it will be MUCH better going forward.

My biggest thing now is that I still feel that my knowledge base is deficient and I don't have a good method for studying. Does anyone have a learning style similar to mine (systematic, like to take my time to understand thoroughly, never really used questions to study during M1/M2 years--just read the text one time VERY thoroughly through, then massive review of all material second run through a few days before the test)? How did you adapt to studying M3 year? (especially for the volume of information covered in Medicine.) Or even if you don't, I would still appreciate SPECIFIC suggestions on how to study that have worked well for you that you think would help. e.g. what exactly does "reading up on your patient" entail? What resources do you use? How do you balance between studying overall content for the shelf exam with studying for miscellaneous topics for the wards, TBL quizzes, and the like?

Thanks again!!

Studied similar to you in M1/M2 and got beat upside the head for it grade wise except in that material that I had the time to read thoroughly....

For MS3 - Case Files is the way to go -- short, sharp, to the point and gives you what you need.

However, try this --- go through First Aid for Step 2 for each rotation you're on, pick the topics in there and then pick a good resource (Like Harrison's) and read the associated chapters for the conditions highlighted in FA. Make notes and include them in a 3 ring binder with that copy of FA that you have now had the cover removed and 3 hold punched. Then after reading both FA and your own notes, do practice questions from UWorld.....

the key to medicine at your level -- not understanding everything in every detail but knowing the basics in sufficient detail -- how do I find that you ask? First Aid and UWorld is the answer -- they tend to cover essential elements of information that give you a good working framework that you can fill in later as you progress in your training. Right now, you need to be able to write an H&P and come up with a reasonable differential at minimum. Then if you can come up with treatments (and not some BS continue current therapy), try to look up workups and then specific meds and dosages....it will only help you in intern year and you'll shine in 3rd/4th....if you can discuss things from articles you have read from the various societies, better for you.....

Key to medicine is building on a good base --- get the framework in place and somewhat fleshed out in medical school....research residencies well and do rotations at the ones you're serious about to gauge toxicity and learning environment/teaching style/ability of attendings -- be SURE to talk to the interns....

You'll do fine, just don't stress out. You can do this...

 

[keedz]

Studied similar to you in M1/M2 and got beat upside the head for it grade wise except in that material that I had the time to read thoroughly....

For MS3 - Case Files is the way to go -- short, sharp, to the point and gives you what you need.

However, try this --- go through First Aid for Step 2 for each rotation you're on, pick the topics in there and then pick a good resource (Like Harrison's) and read the associated chapters for the conditions highlighted in FA. Make notes and include them in a 3 ring binder with that copy of FA that you have now had the cover removed and 3 hold punched. Then after reading both FA and your own notes, do practice questions from UWorld.....

the key to medicine at your level -- not understanding everything in every detail but knowing the basics in sufficient detail -- how do I find that you ask? First Aid and UWorld is the answer -- they tend to cover essential elements of information that give you a good working framework that you can fill in later as you progress in your training. Right now, you need to be able to write an H&P and come up with a reasonable differential at minimum. Then if you can come up with treatments (and not some BS continue current therapy), try to look up workups and then specific meds and dosages....it will only help you in intern year and you'll shine in 3rd/4th....if you can discuss things from articles you have read from the various societies, better for you.....

Key to medicine is building on a good base --- get the framework in place and somewhat fleshed out in medical school....research residencies well and do rotations at the ones you're serious about to gauge toxicity and learning environment/teaching style/ability of attendings -- be SURE to talk to the interns....

You'll do fine, just don't stress out. You can do this...

Super awesome advice! I agree! You can do it!

 

[ashmarj]

Thanks for the replies. I really appreciate it. I had a nice cry about about it yesterday after posting (very much needed) and am feeling a bit better today. It turns out that the team I was on was very much a factor in my feeling overwhelmed--it was the residents' last week on the service, 2 of them were graduating from residency in a month and were pretty much checked out already, and I was working with another MS3 who had already been rotating for a month before me. I just started with a new team of residents and attending who have a much more structured system and are making a good effort to include students in the discussions and incorporate teaching. I think it will be MUCH better going forward.

My biggest thing now is that I still feel that my knowledge base is deficient and I don't have a good method for studying. Does anyone have a learning style similar to mine (systematic, like to take my time to understand thoroughly, never really used questions to study during M1/M2 years--just read the text one time VERY thoroughly through, then massive review of all material second run through a few days before the test)? How did you adapt to studying M3 year? (especially for the volume of information covered in Medicine.) Or even if you don't, I would still appreciate SPECIFIC suggestions on how to study that have worked well for you that you think would help. e.g. what exactly does "reading up on your patient" entail? What resources do you use? How do you balance between studying overall content for the shelf exam with studying for miscellaneous topics for the wards, TBL quizzes, and the like?

Thanks again!!

I'm so sorry you've had such a tough time this year! Teams can definitely make or break your experience on particular rotations.

I was definitely one of those students that learned the most by 'reading up' on my patients. I hated studying just to the shelf exams-so I didn't do it, and focused on learning about my team's patients. For medicine, I actually used uptodate a lot as a resource when I had to look things up on the fly in the hospital, or step up to medicine when I was at home. If it was a really big/important topic, I would also try to find a good (and recent) review article with NEJM.

I also think questions in general are SUPER helpful even if you haven't sat down to read a book-it gets you to think through basic differential diagnoses and work ups (the process) as well as teaching you specifics at the same time. U world is $$, but I used Kaplan through the year cause I wanted to save World for Step 2 studying. I thought Kaplan was decent during actual rotations and shelf preparation (but a horrible qbank for ACTUAL Step 2). If you're looking for other q-books, Appleton and Lange isn't bad. Pretest could be pretty nit-picky in my opinion, but had some decent questions.

Overall I did really well on my rotations and shelf exams with that sort of process. Good luck! Hopefully you'll find a process that works for you!