How to develop confidence as a growing resident

[farri]

How the heck do I become more self confident? I am no longer an intern, and I thought that my jitters would go away because I learned a few things, but I'm still nervous when it comes to certain aspects of patient care. I know I've come a long way since being an intern, but I still feel overwhelmed in how much further I need to go in terms of learning how to adequately take care of my patients. I have this sense of dread whenever patients are acutely decompensating and I feel like I'm just slow to react in an appropriate manner. I feel like I just get jumpy and can't sort through things logically or in a controlled manner. This frustrates me. Even in situations where patients aren't sick-sick, but still not doing well, I just feel like I am missing something or not doing enough when it comes to working up more straightforward things like acute episodes of dyspnea or chest pain. The further I go in residency the more I realize how intimidated I am with the increasing autonomy and at how the juniors look to the seniors for advice. I think part of my problem is that Im slow in translating book smarts into street smarts and good clinical care. I can get test questions right on paper, but it takes me a little while longer to figure the same thing out when I don't have a prompt that can clue me in. Plus I am someone that likes to know too much rather than too little because it gives me this false sense of having knowledge about the unknown, and this in tern makes me slower than my peers.

I don't know if this is normal but this feels pathalogic and I feel like my peers are much better than I am at having or at least feigning confidence and working efficiently. Is this typical growing pains, or are there positive ways for me to change my behavior and thoughts so that I can be less intimidated by patient care and my growing responsibility?

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[Perrotfish]

How do your attendings think that you are doing?

 

[farri]

My attendings think I'm doing fine. They respect my judgement and offer me guidance and tell me my shortcomings, but overall they say I'm doing well and am on par for the course. I think the stupidest thing is that I can't take their word for it. Even though they believe in me, I'm struggling to believe in myself because I'm worried about the day I directly cause someone to have a complication because I didn't know enough or do enough. I don't want to get to the point where I don't care, but I wish I could keep these feelings of anxiety in check more. It's just hard when everyone around you seems so well put together and I feel like I'm the only one struggling to stay afloat.

 

[Perrotfish]

My attendings think I'm doing fine. They respect my judgement and offer me guidance and tell me my shortcomings, but overall they say I'm doing well and am on par for the course. I think the stupidest thing is that I can't take their word for it. Even though they believe in me, I'm struggling to believe in myself because I'm worried about the day I directly cause someone to have a complication because I didn't know enough or do enough. I don't want to get to the point where I don't care, but I wish I could keep these feelings of anxiety in check more. It's just hard when everyone around you seems so well put together and I feel like I'm the only one struggling to stay afloat.

So if by 'confidence' you mean not feeling anxious about your patient care, then you're not supposed to have much confidence yet. That anxiety is supposed to be pretty intense until at least your second year as an attending. If you're planning on being a good attending it should still be present, though at a much lower intensity, for the rest of your career. Its what drives you to read, to go to conferences, to do CME, and in general to improve yourself. Most of the people around you who seem like they're confident are struggling with the same anxieties. The remainder are probably really dangerous.

You should, however, be confident that you are going to get through this. If you're an R2 and your attendings still think you are making the grade you should have confidence that, if you keep working hard, you will get to the point where this feels natural in only 3 or 4 years, and that each day will be a little bit better than the last.

 

[gutonc]

So if by 'confidence' you mean not feeling anxious about your patient care, then you're not supposed to have much confidence yet. That anxiety is supposed to be pretty intense until at least your second year as an attending. If you're planning on being a good attending it should still be present, though at a much lower intensity, for the rest of your career.

I'm in my 7th year out in the wild and I only get this feeling 5 or 6 times a week (out of 60+ patient contacts in 3 days of clinic) now. I'm pretty sure I'm killing it.

If I get down to once or twice a week, I'll know it's time to retire because I'm not paying enough attention.

 

[Redpancreas]

Realize that every bit of pain you feel is god/nature's way of pushing you to succeed. You may never embrace that pain, but learn to step back from it objectively and appreciate it. Also, get plenty of sleep and don't try to repeat medical school (staying up reading random junk). You need those sleep cycles to learn how to be a resident. That said, I'm an intern.

 

[BigPikachu]

Practicing medicine is as much an act of appearing confident and demonstrating yourself to be a leader, as much as it is about having the actual knowledge and experience to. As a junior doctor, I suppose you have to rely on more of the 'acting' part and adopting methods from your colleagues, since knowledge and experience inevitably takes time to acquire.

There are many different techniques and methods on how to appear to be confident and a clinical leader which can be self-taught and learnt through simulations and workshops -- which are meant to be safe environments to attain and practice these skills; books only get you so far, you also need to practice clinical skills, and simulations nowadays seems to be the way to go with this -- just as pilots practice in simulations, there's a push for medicos to similarly practice in a simulated environment on a more regular basis to allow for more reflection and learning opportunities -- the faculty attendings/consultants are the ones who should be facilitating this during teaching sessions.

That said, the most useful piece of advice I can give you is to absorb the good qualities of how your consultants/attendings approach clinical scenarios and adopt them to use in your own individual way. To this day, I still 'copy' the same approach a previous palliative care physician I used to work with delivers bad news and approaches end-of-life decision choices; the same goes for my approach to major trauma and resuscitations is very much based on what I have taken away from a combination of what I thought to be the best qualities and approaches of esteemed supervisors in emergency medicine I've had the pleasure of working with during my traineeship. So in effect to this day I'm still 'acting' or 'mirroring' my old supervisors, but hopefully with some of my own individual approaches that I've evolved into with my own experiences. This is effectively the purpose of a residency/registrarship is to take on an apprenticeship to pick-up these skills you can't learn from a book but on the floor and at the bedside with your supervisors.

And don't worry so much about other people; competition is healthy to a point that it becomes an envious obsessive exercise that only adds to your anxieties.

 

[evilbooyaa]

If your attendings say you're doing fine then you're doing fine. Take their word for it. Fear is normal at times when caring for patients. Don't let it paralyze you and stop you from doing what you know you can do.

 

[OrthoTraumaMD]

Read. Keep reading. Journals, textbooks, whatever you can. Knowledge of your trade is the key to confidence.


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[obgyny]

Confidence comes with time and experience. It will come to you. You just started 2nd year.

I think much of what you are feeling is normal, but as others said, don’t let it cripple you. If your attendings think you’re doing well, then you’re doing just fine. I think you should have a healthy dose of fear to keep you diligent and motivated to keep improving your knowledge. I don’t trust the junior residents who are overconfident...

Sounds like you’re suffering from the Imposter Syndrome. Heck, I’m in my 4th year of residency and I still feel like an imposter at times. I think of myself as an anxious person, but my attendings and junior residents comment on how calm and confident I appear. Sometimes you just can’t see it for yourself.

Don’t forget to look back every once in a while and remember how far you’ve come. When you’re teaching your interns, you’ll see just how much you’ve learned. Take your fear and use it to learn as much as you can during residency (and after).

“Fake it ‘til you make it” is very much relevant in residency.




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[mvenus929]

I started fellowship about a month ago. I contacted my residency PD for some reason, and she asked how I was doing. I said I was in a perpetual state of confusion—our fellowship hasn’t had fellows that didn’t already know the system for at least 3 years, so figuring out what all needs to happen to get us up as functional fellows has been challenging. She responded that she has never known me to live in confusion. Yet, intern year, I distinctly remember staring at a progress note wondering what the heck I was supposed to write on what seemed like a stable patient.

I tell this story just to illustrate that your perception of your abilities does not always line up with reality. In fact, all our residents fill out self-assessments every year, and it’s sometimes comical to see how highly some people think of themselves compared to how their attendings think of them, and sad to see that the truly outstanding residents think they are doing very poorly. Trust us, if you were truly having issues, people would let you know.

You’re also at the point where you actually know what you don’t know. Or are aware that there is a lot you don’t know. Some people aren’t at that point, and that makes them dangerous.

 

[dienekes88]

Put your nickel down and see how often you are right. Too often folks try to avoid being wrong, so they don't commit to an answer. The more often you commit to an answer and are wrong, the faster you should start getting things right.

Write down every attending's preferences. Have a keen eye toward seeing which patients do better.

Avoid 1-step algorithms. Use your understanding of physiology to come up with logical ways of approaching complicated patients.

Hopefully, if you present a well-reasoned plan to your attendings, your attendings will let you grow as a physician by only gently nudging you this way or that.