I am a terrible resident

[anonmouse]

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About halfway through intern year and I am struggling. There's nothing glaringly terrible that has happened but I feel like I have learned almost nothing and am lagging behind the other interns, who talk about the compliments they have received from attendings. Meanwhile my reviews are lukewarm at best. The med students I work with seem smarter and more together than I do. When I try to de-escalate patients they get even more agitated. I've been told I should appear more confident, but how am I supposed to do this when I don't even know what I'm talking about?

 

[Old&InTheWay]

That's an awful feeling and you are certainly not alone among residents in feeling this way. Do you have a sense of what kind of psychiatrist you want to become? I mean, what are your values? I think that finding an authentic professional identity is very important. And perhaps you already are, but what you are talking about is very good material to explore in supervision, but also (and probably more importantly) in therapy. You are almost certainly learning. My suspicion is that there is something else underlying your concerns about how you are doing as a resident.

 

[robellis]

About halfway through intern year and I am struggling. There's nothing glaringly terrible that has happened but I feel like I have learned almost nothing and am lagging behind the other interns, who talk about the compliments they have received from attendings. Meanwhile my reviews are lukewarm at best. The med students I work with seem smarter and more together than I do. When I try to de-escalate patients they get even more agitated. I've been told I should appear more confident, but how am I supposed to do this when I don't even know what I'm talking about?

This is very normal..also you don’t need to de-escalate patients that’s the nurses job just walk away..you’re still learning there’s a reason it’s 4 years it gets easier

 

[DOswag]

Anonmouse it's not easy going through this. Intern year is tough. I can guarantee you've learned something this year and probably a lot more than you're giving yourself credit for. I can also guarantee that you're not the only one feeling this way even if your perception is that other interns are ahead of you. I recall having similar feelings at times during my intern year. When some of us would go out, even the ones that I felt were way ahead of me admitted similar feelings throughout the year. Interns aren't supposed to be confident. It takes a while to start feeling confident in what you're doing because you've only been a doctor for 6 months. The upper level residents have a couple of years on you and have already seen much more than you have. Attendings have years to decades on you. I had to keep reminding myself of this during training as well. Keep pushing, reading as much as you can and seeing as many patients as you can. It'll come in time. When the next batch of interns come in next year, you'll realize how much you grew through the year.

 

[Monocles]

OP the fact that you are able to reflect on this means you are probably in the upper half of interns. My expectations for pgy-1s is... to be able to find the bathroom and figure out the EMR during their first year lol and you would be surprised how many still struggle. You are likely way more clinically capable and competent than you give yourself credit for. Besides residency is four years... you've got plenty of time to figure it out. Don't compare yourself to your peers, compare yourself against your own progress. "

You've got this friend!

 

[deleted1100659]

About halfway through intern year and I am struggling. There's nothing glaringly terrible that has happened but I feel like I have learned almost nothing and am lagging behind the other interns, who talk about the compliments they have received from attendings. Meanwhile my reviews are lukewarm at best. The med students I work with seem smarter and more together than I do. When I try to de-escalate patients they get even more agitated. I've been told I should appear more confident, but how am I supposed to do this when I don't even know what I'm talking about?

If you feel like theres a knowledge gap then buy the maudsley prescribing guidelines, read that and youll sound smarter than the rest of your class. Amazing book, its very easy to read through.

Confidence gap? That takes time. Even if you arent 100% sure sometimes its ok to still be confident. Have faith in yourself. You made it this far. Every treatment plan you formulate know what you would do at the next visit/follow up so you have a plan A, plan B, etc. Plan for error (which takes time to do sometimes). Sometimes a patient will respond better to you in the treatment plan if you project confidence, even if sometimes a false confidence, lol. Sometimes theres nothing wrong with projecting false confidence, as long as its not masking ignorance.

You are most likely not terrible. The best way to learn is to read, and also to reflect upon your experiences with patients. Whats worked? When were the outcomes good?

If a patient is aggressive then most of the time verbal de-escalation will fail anyways and I never put myself in a position to where they can yell at me or assault me, I value my life too much for that.

Be objective with yourself. Think of specific situations where you feel you did something that was not up to par. What could you have done differently? How do you learn and grow from it?

 

[tr]

About halfway through intern year and I am struggling. There's nothing glaringly terrible that has happened but I feel like I have learned almost nothing and am lagging behind the other interns, who talk about the compliments they have received from attendings. Meanwhile my reviews are lukewarm at best. The med students I work with seem smarter and more together than I do. When I try to de-escalate patients they get even more agitated. I've been told I should appear more confident, but how am I supposed to do this when I don't even know what I'm talking about?

Obviously if people are bragging about their evals (who does this btw?) then they are not choosing the lukewarm ones to display. This is like comparing your own actual life as you experience it to everyone else's glowed-up Instagram representations of their lives.

As far as de-escalating, this is a critical skill but agreed with above posters that you have tons of time to learn it. You are an intern; you are there to learn.
I recommend the following resource for dealing with agitated, guarded, angry, or otherwise difficult patients in any clinical setting.

The website of David D. Burns, MD | 014: The Five Secrets of Effective Communication (Part 1) | Feeling Good

Practically all of us have a friend, colleague, client, customer or family member we aren’t getting along with very well. Perhaps the difficult person in your life is excessively critical of you, complains constantly, won’t express his or her feelings, always has to be right, or never listens to...

feelinggood.com

 

[robellis]

Obviously if people are bragging about their evals (who does this btw?) then they are not choosing the lukewarm ones to display. This is like comparing your own actual life as you experience it to everyone else's glowed-up Instagram representations of their lives.

As far as de-escalating, this is a critical skill but agreed with above posters that you have tons of time to learn it. You are an intern; you are there to learn.
I recommend the following resource for dealing with agitated, guarded, angry, or otherwise difficult patients in any clinical setting.

The website of David D. Burns, MD | 014: The Five Secrets of Effective Communication (Part 1) | Feeling Good

Practically all of us have a friend, colleague, client, customer or family member we aren’t getting along with very well. Perhaps the difficult person in your life is excessively critical of you, complains constantly, won’t express his or her feelings, always has to be right, or never listens to...

feelinggood.com

this Is a good way to get punched in the inpatient setting.Inpatient is about safety not sharing “I feel” statements with the psychotic methhead

 

[littlefred]

this Is a good way to get punched in the inpatient setting.Inpatient is about safety not sharing “I feel” statements with the psychotic methhead

Using pejorative terms like that for patient with SUD doesn't help with the stigma and frankly, makes you sound unprofessional.

 

[robellis]

Using pejorative terms like that for patient with SUD doesn't help with the stigma and frankly, makes you sound unprofessional.

Unprofessional!? Take it back!! I can’t bear that burden of sounding unprofessional!!! There’s a stigma because there should be a stigma..some people make dumb choices and should be stigmatized for it..this is not always the case but it certainly is at times

 

[tr]

this Is a good way to get punched in the inpatient setting.Inpatient is about safety not sharing “I feel” statements with the psychotic methhead

I have repeatedly used Five Secrets to effectively de-escalate agitated patients in the inpatient, ER, or C/L setting. There is also an active thread right now on how best to inform inpatients of involuntary hold status, on which several inpatient attendings describe how they use this type of skill to manage difficult interactions with inpatients. This is a central skill set that all psychiatrists should have. Kudos to the OP for recognizing that it is important, and also a learned skill.

BTW I think the most effective of the Five Secrets is actually not I-Feel, but Disarming. Try saying these two magic words to your next agitated patient: "You're right." See how quickly their aggressive stance collapses and they become instantly more open to what else you have to say.

However, 'I-Feel' can also be helpful. In residency I had a very experienced attending who specialized in chronic psychotic illness. He used to tell his patients straight up if he was feeling afraid of them. It was like magic. They would back down the aggression because of course, it was coming from their *own* fear.

 

[FlowRate]

I was trying to find the videos I had liked about de-escalation techniques but didn't find it on some brief searching. I did come across this series from CO SOM that seem pretty well cone.

 

[comp1]

It's kind of bizarre that your co-residents are talking about compliments they get from attendings... I do not remember that happening. We'd definitely joke about the attendings... I second the above about interns only really needing to learn the EMR. If you aren't actually getting complaints...you're doing fine. I'm not sure where the expectation for glowing reviews comes from. Attendings are well aware that outside of serious problems, resident reviews aren't used for much.

 

[Psychresy]

It's kind of bizarre that your co-residents are talking about compliments they get from attendings... I do not remember that happening. We'd definitely joke about the attendings... I second the above about interns only really needing to learn the EMR. If you aren't actually getting complaints...you're doing fine. I'm not sure where the expectation for glowing reviews comes from. Attendings are well aware that outside of serious problems, resident reviews aren't used for much.

Yeah this is a weird thing for residents to be bragging out. Not common.

 

[MacDonaldTriad]

I think we should bring this back to anonymous as he/she began this thread. What you are experiencing is modal and far from rare. Any classmates who brag about their stellar evaluations should sod off and be considered a first class wankers. You are thrown into the role of being a psychiatrist and the hardest part is the beginning when you are expected to be competent and should be bad at it by all expectations. This is a 4 year marathon and not a sprint. Our ability to predict who develops well vs who is going to "graduate" less than average is poor at best. It is more about your learning curve than where you start. Be honest, tell your mentors you are struggling and need help. Listen to what they suggest, everyone has a lot of interest in your success. It takes a village to grow psychiatrists and it is best to take advantage of all opportunities that are available. Trainees who do not do this miss out. If you dive in and go for it, you will surpass most people in your class and you will end up the richer for it.

Buck up and aim high. You will do this. Happy holidays,

 

[DOBound2019]

Intern year is a massive learning curve and honestly all of us suck, all of our notes are lacking, and all of us have to go back multiple time to ask questions we forgot in the initial interview because that's how it is to start. The only people who may seem "ahead" are maybe interns who were also students at the same program and they aren't actually ahead of you clinically they just are lucky to be a little more familiar with the system. Echoing what macdonaldtriad said as long as you seek out feedback and accept it without defensiveness you'll grow and be a great psychiatrist. Continue reading, learning, working hard and reflecting and you will be great by the end.

 

[Dharma]

Sounds like you are doing well OP: mindful, humble, and motivated. Add a dash of confidence because you have the chops!

Keep at it!

 

[whopper]

I've seen residents not perform well. A family member of mine is a resident and I saw several issues with her suggesting she had at least a few sub-par traits. Bottom line is we don't know how good or bad this resident really is. We shouldn't say "you're doing fine" when in reality that person may really be terrible. We don't know.

The OP doesn't give us enough information IMHO to give any useful feedback. E.g. if the person has problems with de-escalation we ought to have seen or gotten detailed information the person's accounts of what happened and what methods they are using. Offering information on how to do it better is great, and if not being done by his/her/their program that's the program's fault but we can't say this person is or isn't doing an appropriate level of performance.

All this said, being in residency is tough, and I was in a pickle in residency because of lack of instruction. This is a major reason why I adhered to these forums while a resident but enjoyed it too much to leave. People not performing well deserve good instruction and direction to improve themselves and sometimes residents are in a toxic culture where the attendings may not be doing their teaching responsibilities well.

 

[Marasmus1]

I haven`t yet met an intern who is not struggling. Actually, the ones who feel they are doing well tend to be the most struggling ones based on my experience.

 

[whopper]

My first rotation my attending did no teaching. He pretty much left me alone in a psych ER and because I wasn't able to lighten his load much complained about me. That was my only rotation where I had a negative review. As I progressed in residency, people told me later on that this guy was a graduate of the same program and one of the worst residents they ever graduated and was known to be lazy. Such things aren't told to first-years.

So my first rotation I thought I wasn't doing well and I really wasn't doing well but it was really on him and not me. Seriously he didn't even do the bare minimum such as show me an admission template. I was pretty much just sitting there not knowing WTF to do. When I was chief resident I knew the residents assigned to this guy first rotation wouldn't be taught on the bare minimums so I had to step on and do what this guy should've done.

During my year as chief, things were told to me such as "he was hired because he was willing to take the job for low reimbursement" and that several believed he took the job because he wanted to dump most of his work responsibilities onto a resident. One of those things they don't teach residents as part of the official curriculum-that is the reality of what's going on behind the curtain.

 

[elbandito1]

With De-escalation, it really all depends on the context. If it’s a floridly psychotic patient whose having a total outburst because “the martians are following him” and they must bang their head on the wall repeatedly or whatever else they’re doing, I doubt you’re going to have much success in actually verbally De-escalating them. PRNs / IMs…don’t feel pressured by the nurse when they come up to you and say “you need to talk to mr / ms X.” I agree it’s certainly important to strengthen this skill, but I wouldn’t be too hard on your self and with experience, you’ll get better at determining how best to intervene. Agree with what others have posted in that you’re absolutely not on your own in feeling inadequate. It will get better! I was quite anxious and also felt I was weaker than the rest of my cohort, but I ended up (I feel at least) as a stronger performer by the end of residency, and presented with several awards to support that. Reflect on your weaknesses (which you are) and take as much feedback from your supervisors as you can

 

[Auvelity]

I would agree. I felt the same way during my intern year. It def didn’t help that my residency doesn’t offer that much guidance and we are more work of labor, but I had my own limitations such as being an IMG, not familiar with EMR, honestly too tired to even pick up a book. While I thought all of my co-interns were doing splendid, I felt I was just keeping myself above water, you are not alone.

Now that you realize that there are some skills you are lacking, now is the time to search for a nice pocket book, even if it’s just DSM differential guide, read upon your cases, read upon medications you see as you see the patients. learn how to handle the basics, when other teams will come to you as the psychiatrist for delirium, mania, suicidal ideation and agitation and expect from you to be able to recognize and manage right away.
I would know first line medications you can find at your hospital for acute agitation, doses and EKG/safety parameters. Benadryl, Ativan and Haldol was all I used first year until I started reading more and would prefer Haldol/Zyprexa if delirium vs ativan if it’s agitation due to alcohol withdrawal…

And in regards of de-escalation, you will learn. I know at this time it doesn’t help. But a good rule of thumb is “trust your gut”, if the patient is actively yelling to staff and appears threatening (ready to charge at someone) I would medicate first and ask questions later. you could definitely try to speak to patient and verbally de-escalate as long as your security staff is ready for any contingency. And if you feel the psychosis or agitation wouldn’t respond to verbal de-escalation because of intoxication or other factors a good rule of thumb is to medicate. You can attempt later once patient calms down.
Now another scenario is being paged for agitation just because the person is crying for some reason. If they look calm majority of the times they just want to be listened to and just by trying to listen patient will most likely calm down.

Good luck!

 

[Fabio001]

OP, please get yourself some therapy. Also, I advise informing and seeking feedback/coaching from your program director and maybe one or two trusted and high-quality supervisors. They'll be able to offer you more specific feedback than what you'll get here. If for any reason you don't feel comfortable bringing up these issues with supervisors, start with therapy. I'm really sorry you're struggling, but seriously, intern year is not great for anyone. I don't think I ever felt so incompetent in my life.