How to keep sharp and update on medical knowledge post residency and board exam! Feeling like a fraud as a junior faculty!

[Lilyhopeless]

I have just graduated from my residency this year recently board certified by ABIM (so now got promoted to paying the MOC mafia...). I am working now as a junior academic faculty since mid-September in another medium sized Academic center (some 80+ total cat and prelim residents)

My question is after the board passing and graduation, it is hard to motivate myself to learning as in the great amount of reading we all do in residency.
With that being said, I am so jealous of all the senior attendings and my former attendings who are so sharp with their management and could foresee so far more or less accurately the course of a patient's progress! Granted, most of them has at least a decade of experiences above my head but, I'll be honest, it is intimidating and inspiring.

During grand-round and M&M, the attendings ask such illuminating and incisive questions that my dumb brain was just blown away! I couldn't help but be inspired and well, once again, intimidated!!! Case in point, a blood gas was on presentation last week and I am still calculating on MedCalc but this >70-years-old attending just called out the gap, the delta gap and everything right then and there. TBH, rude really, since he did not give the residents a chance to go through it before he gave out the answer but it is still impressive to me!

Further, my senior 3rd year residents are so smart too even some interns and 2nd years too! I don't know about you guys, senior attendings, but, at times, I am intimidated by my senior residents. There were times that I was thinking "I would not have known that when I was in their shoes" or "Dang, that is a perfect answer if I ever was looking for one!" or "Uptodate couldn't have written a better explanation!". Multiple times my hands are twitching to check uptodate for confirmation! I chart-reviewed on all my patients pre-rounding too so it wasn't because the patients were new to me but these residents are good!

So, now I am back to reading books like Framework of Internal Medicine and etc that I used to do as a resident. But I want to know whether you, senior attendings here, ever been in my shoes or is it just me?! Second, what kind of resources do you guys use to keep up with new medical knowledge and solidify the old ones that you previously learnt? Really, how do you guys keep yourself sharp over the years and decades to come!

Sincerely,

Intimidated PGY4; still can't believe I passed my board and my chair allowed me to be an attending to someone!

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[dgdg]

Learning is life long. It never ends, but that is a wonderful aspect of medicine.
Many of those you interact with may likely feel the same way but hide it.

Read about your patients' conditions. Pick a patient, a topic and find something to read - review article, UpToDate topic, etc.
Create AnkiDroid flash cards on your phone for pure facts (ex SBP criteria, PFTs, ABGs, etc) that you want to keep in your brain for quick recall.
I like NEJM online magazine, and also their Journal Watch for updates. Quick reads.

 

[timpview]

Reading more books isn’t going to help you.

You just need to change your mindset.

You’re more than qualified to do your job. It’s a job. Just do your best and realize that you’re at least better than 99%+ of the midlevels that do your same job

 

[NewYorkDoctors]

During grand-round and M&M, the attendings ask such illuminating and incisive questions that my dumb brain was just blown away! I couldn't help but be inspired and well, once again, intimidated!!! Case in point, a blood gas was on presentation last week and I am still calculating on MedCalc but this >70-years-old attending just called out the gap, the delta gap and everything right then and there. TBH, rude really, since he did not give the residents a chance to go through it before he gave out the answer but it is still impressive to me!

i assume you are a hospitalist, PCP, or private internist who does in and oupatient?

any anion and delta gaps are simple arithmetic...
but as with anything you get "better at it" the more repetitions you get with the same cases.
As an Internist you need not be "an expert at everything." You merely need to "recognize everything" and know when a specialist is needed. (in my viewpoint, it's when the clinical trajectory is not expected to resolve quickly and more is needed than just prescribing medications)

You also need lifelong learning.

UpToDate is not really for learning something new IMO. It's great for "filling in the knowledge gaps" IMO.

I like to watch the lectures on VuMedi. I don't get paid by them so I am not shilling for them. yes they are paid by industry.... but their lectures are usually given by the top academic faculty and leaders in the topic's field. Feels like grand rounds on a phone. I learn so much.


anyway just keep doing what you are doing. Usually an attending begins to feel in his/her shoes about 2-3 years out.
Like they taught you in med school, it's totally to admit you don't know the answer to everything. But as long as you know HOW TO GET the answer, then that's fine.

 

[c0pycat]

i assume you are a hospitalist, PCP, or private internist who does in and oupatient?

any anion and delta gaps are simple arithmetic...
but as with anything you get "better at it" the more repetitions you get with the same cases.
As an Internist you need not be "an expert at everything." You merely need to "recognize everything" and know when a specialist is needed. (in my viewpoint, it's when the clinical trajectory is not expected to resolve quickly and more is needed than just prescribing medications)

You also need lifelong learning.

UpToDate is not really for learning something new IMO. It's great for "filling in the knowledge gaps" IMO.

I like to watch the lectures on VuMedi. I don't get paid by them so I am not shilling for them. yes they are paid by industry.... but their lectures are usually given by the top academic faculty and leaders in the topic's field. Feels like grand rounds on a phone. I learn so much.


anyway just keep doing what you are doing. Usually an attending begins to feel in his/her shoes about 2-3 years out.
Like they taught you in med school, it's totally to admit you don't know the answer to everything. But as long as you know HOW TO GET the answer, then that's fine.

Just signed up for VuMedi...looks decent...how do you personally utilize it?? Just like the OP...I just finished IM residency and started working as a Hospitalist/Nocturnist.

 

[rokshana]

i assume you are a hospitalist, PCP, or private internist who does in and oupatient?

any anion and delta gaps are simple arithmetic...
but as with anything you get "better at it" the more repetitions you get with the same cases.
As an Internist you need not be "an expert at everything." You merely need to "recognize everything" and know when a specialist is needed. (in my viewpoint, it's when the clinical trajectory is not expected to resolve quickly and more is needed than just prescribing medications)

You also need lifelong learning.

UpToDate is not really for learning something new IMO. It's great for "filling in the knowledge gaps" IMO.

I like to watch the lectures on VuMedi. I don't get paid by them so I am not shilling for them. yes they are paid by industry.... but their lectures are usually given by the top academic faculty and leaders in the topic's field. Feels like grand rounds on a phone. I learn so much.


anyway just keep doing what you are doing. Usually an attending begins to feel in his/her shoes about 2-3 years out.
Like they taught you in med school, it's totally to admit you don't know the answer to everything. But as long as you know HOW TO GET the answer, then that's fine.

I think they are a chief resident

 

[dozitgetchahi]

I have just graduated from my residency this year recently board certified by ABIM (so now got promoted to paying the MOC mafia...). I am working now as a junior academic faculty since mid-September in another medium sized Academic center (some 80+ total cat and prelim residents)

My question is after the board passing and graduation, it is hard to motivate myself to learning as in the great amount of reading we all do in residency.
With that being said, I am so jealous of all the senior attendings and my former attendings who are so sharp with their management and could foresee so far more or less accurately the course of a patient's progress! Granted, most of them has at least a decade of experiences above my head but, I'll be honest, it is intimidating and inspiring.

During grand-round and M&M, the attendings ask such illuminating and incisive questions that my dumb brain was just blown away! I couldn't help but be inspired and well, once again, intimidated!!! Case in point, a blood gas was on presentation last week and I am still calculating on MedCalc but this >70-years-old attending just called out the gap, the delta gap and everything right then and there. TBH, rude really, since he did not give the residents a chance to go through it before he gave out the answer but it is still impressive to me!

Further, my senior 3rd year residents are so smart too even some interns and 2nd years too! I don't know about you guys, senior attendings, but, at times, I am intimidated by my senior residents. There were times that I was thinking "I would not have known that when I was in their shoes" or "Dang, that is a perfect answer if I ever was looking for one!" or "Uptodate couldn't have written a better explanation!". Multiple times my hands are twitching to check uptodate for confirmation! I chart-reviewed on all my patients pre-rounding too so it wasn't because the patients were new to me but these residents are good!

So, now I am back to reading books like Framework of Internal Medicine and etc that I used to do as a resident. But I want to know whether you, senior attendings here, ever been in my shoes or is it just me?! Second, what kind of resources do you guys use to keep up with new medical knowledge and solidify the old ones that you previously learnt? Really, how do you guys keep yourself sharp over the years and decades to come!

Sincerely,

Intimidated PGY4; still can't believe I passed my board and my chair allowed me to be an attending to someone!

Do your job. Do as well as you can. Go home, learn a bit, and get on with your life.

I consider myself well read as a rheumatologist, but man, I don’t miss the endless penis measuring, boasting, and posturing that seemed to characterize the lives of academic physicians. I was very happy to get that phase of my career over with.

 

[NewYorkDoctors]

I think they are a chief resident

oh i see. right that PGY-4 comment makes more sense now.

still chief residents are expected to cover hospitalist shift at times and lead resident floor teams.

the same advice still applies in that case.

 

[NewYorkDoctors]

Just signed up for VuMedi...looks decent...how do you personally utilize it?? Just like the OP...I just finished IM residency and started working as a Hospitalist/Nocturnist.

brush up on topics that I might see sometimes or to strengthen my management of rare cases.

In fellowship, I worked up and managed a few Type 1 PAH patients during the PH rotation. But this is a rare disease overall in the community. While I can answer the board questions, I cannot say I can manage it blind and know what exactly to do in every case. I have recently worked up a patient for dyspnea and cardiologist found echo PASP 75mmHg. Workup eventually prompted RHC showing mPAP 46, PCWP 12, Woods unit 15. no vasoreactivity. Precapillary PH. Whoa nellie we got a live one on the line. PFTs and sleep study shows GOLD1 COPD (the A and B are hard to discern due to COPD), V/Q scan in progress (this is rather hard to get in the community... i mean insurance PA is one thing that's not too hard with proper documentation, but it's finding the proper hospital based radiology center that has nuclear medicine and whom the insurance is in network with!) , CPET convincingly supports Type 1 over Type 3. The patient has NYHA Class 3 symptoms. I recall start with endothelial antagonist and PDE5i as first line dual therapy. But I was hazy on the details.
Vumed's pulmonary hypertension expert lectures got me quickly refreshed and on track.
(anyway this patient should be managed in an academic center of excellence for parenteral prostacyclin therapy but he refused because..... he could actually walk far enough to even reach his transportation! but it is the next step of his management.)

I also listen up on topics for disease processes I see often to hear about new updates and new treatment options.

Once in a while I would listen to some topic I just have a personal interest in!

But hey I listen to this while I Drive. it sure beats listening to political / social media stuff on youtube on the drive home! While that stuff is entertaining, it's not exactly Mozart for the ears.

Perhaps for a hospitalist/ Internist, if you find yourself often wondering "hmm why did specialist X,Y,Z always order these things... I could order that too to save time in the future and perhaps shave time off of the length of stay.. hmmm... let me listen to some lectures" seems to be a good way to use this learning tool. Back in IM residency during admission, I would always try my best to "win the game" (discharge floor team list to zero before the next call cycle). That happened once or twice. Usually would get each intern's census down to 1-2 / 10 at the start of a call day.
how? well a lot was luck... have to not get the "dead end dispo" cases.
Another one was always talking to family every day and "framing the conversation correctly."
But something else was get as much (appropriate) workup done on Day 1 of the admission so the consultant's have the consult on a silver platter and cannot give you a "order basic workup today. ill follow up tomorrow or sometime" consult.

in my PGy3 year, I recall cirrhotic came in with hematemesis. not so sick to require ICU.
Pocket Medicine cookbook management was done
2 16G IVs (lol... that's not happening in real life. those things are huge. I did get 18G under ultrasound placed in the brachial veins with long IVs) the pRBCs, the FFPs, the albumin infusions to prevent HRS, the ceftriaxone for SBP prophylaxis, the octreotide drip, the PPI drip... literal cookbook medicine... GI saw after this and quickly wrote "agree with primary team" and schedule for scope the next day quickly. Scope done. CBC monitored a few days. no further evidence of bleeding. capsule endoscopy administered to patient and discharged on Day 3 or 4 or something.

something inappropriate would be if some "bookworm" intern is admitting a patient with uncontrolled diabetes... technically meets criteria for DKA but ICU rejected it because the AG was not that high and patient would be managed with parenteral insulin on the floors... decides to order islet cell, GAD Ab, anti insulin because he/she just read the MKSAP diabetes chapter... then patient is discharged and those lab results have not returned yet... enters resident's inbox later... no attempt is made to get these results to PCP or outpatient endocrinologist.

 

[Meerkatology]

Intimidated PGY4; still can't believe I passed my board and my chair allowed me to be an attending to someone!

i feel the same way, i am now 10 years out from my residency, have been working fairly low volume nocturnist admitting jobs.
i didnt feel ready to be a teaching attending out of residency, and i wouldnt feel ready now. if i worked busy day job for 10 years maybe i would?

i do however, feel i am reasonably qualified to do my current job - if u test me on some academics im sure ill be worse at those than i was as a pgy3... but i do see the same kind of patients over and over so many times, i usually know exactly whats wrong the moment i lay eyes on them and can predict what will happen with them in the next 3 days, i guess that comes with repititon?
i think you do become comfortable at being your patient's attending over time but being a teaching attending is something else entirely, espeically at an academic center.

going from PGY3 to attending is just 1 day but we don't magically change into who our mentors are. maybe we'll get there some day , maybe not, it really depends on the life that you want. u could treat medicine as just a job for the rest of life, doing some uptodate surfing when needed. or u could treat it like a passion, actively seeking knowledge all the time and become a teaching attending someday.

i think ur environment is going to force u to learn anyway, in a few years time you'll probably feel perfectly ready. the fact that you are doubting your ability means you are already actively trying to improve, self doubt is a very good quality in this field as IM attendings we are not expected to know everything anyway, thats what consultants are for, knowing your limits is still a very good thing for your patients.

lastly, you are probably comparing yourself to your mentors - they are likely the cream of the crop. the average doctor you run into as a coworker have varying levels of competency or even professionalism. you may not be perfect, but neither are your peers.

 

[jm192]

I started as a hospitalist 6 years ago, and felt so overwhelmed. It's terrifying being the adult in the room. I thought I wasn't good enough/smart enough. But I kept people alive. I probably over-consulted at the start. But I learned from every consult. And unless it required a procedure, the next time I wouldn't consult on that.

I read a crap ton of uptodate at the start. I still read it a few times a week, but nothing like at the start. I saw 1 thyroid storm in Residency, and then got to treat a patient with it my first 6 months as an attending. No endocrine. Just doing the things the best I could. Patient got better and saw Endocrine outpatient.

I went to every code and rapid. I don't know how that part works as faculty. But when things are at their worst, you learn to think rather quickly. And I went from thinking I'm not sure I'll ever be able to handle these--to someone the nurses were relived to have show up.

Lastly, taking transfer calls really helped my confidence. Not to be a jerk about it, but I've talked to ER doctors, hospitalists, and even an intensivist that I felt were missing the actual problem--or imagining a problem than didn't really exist. Go through enough of those phone calls, and you'll realize you're not below average.

 

[dgdg]

I started as a hospitalist 6 years ago, and felt so overwhelmed. It's terrifying being the adult in the room. I thought I wasn't good enough/smart enough. But I kept people alive. I probably over-consulted at the start. But I learned from every consult. And unless it required a procedure, the next time I wouldn't consult on that.

I read a crap ton of uptodate at the start. I still read it a few times a week, but nothing like at the start. I saw 1 thyroid storm in Residency, and then got to treat a patient with it my first 6 months as an attending. No endocrine. Just doing the things the best I could. Patient got better and saw Endocrine outpatient.

I went to every code and rapid. I don't know how that part works as faculty. But when things are at their worst, you learn to think rather quickly. And I went from thinking I'm not sure I'll ever be able to handle these--to someone the nurses were relived to have show up.

Lastly, taking transfer calls really helped my confidence. Not to be a jerk about it, but I've talked to ER doctors, hospitalists, and even an intensivist that I felt were missing the actual problem--or imagining a problem than didn't really exist. Go through enough of those phone calls, and you'll realize you're not below average.

Sounds like you really availed yourself. Good job and inspiration for others.

One may never know as much 'book smarts' as they did in residency, but there are gaps in that knowledge (and experience) too - ever learning.
I think I over studied for my last 10 year MOC exam. I wound up learning some new things that are useful, and re-memorized some old things that don't come up much and typically will review in UpToDate. I scored better than my initial cert exam, if that means anything as a metric.

I think despite all the corporate pressures on us as a profession, loving the essence of medicine, an eagerness to learn and be curious, and wanting to do good for our patients will keep us sharp. Just like you are doing.