im a 4th year...any advice on how to not kill a patient?

[herpes]

im a 4th year, and i still dont know what is going on. i feel so lost when taking care of the patient. especially since calls are made to the resident and the resident is the one who is usually updated on what's going on with the patient. the residents also put in the orders, since med students arent allowed to (would cause residents more of a headache if they did). when presenting the patient to the attending, i dont know what to present because i dont know what is importnat...

how can i be a better clinician...?? i want to give excellent care to patients and be prepared for my intern year. however, a lot of times, i feel so overwhelmed with what's going on with the patient that i get confused and sometimes mix the patients up...

thanks!

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[markglt]

:troll:

 

[LuckyBambooGirl]

First of all, relax! You as a fourth year med student are not going to kill anyone! Try to work more closely with your resident. Ask them if they have heard anything new about their patient, ask them what kind of orders they are putting in, etc. Try practicing your presentation on your resident first and getting feedback from them before you present for the attending.

 

[SouthernSurgeon]

Can't you just read the history chart and ask questions to the patient yourself?

Sheesh, sometimes med students on the rounds can be soo annoying with their skimminess. I had a student (really nice chap) the other day and he didn't want to help me with a freaking history chart (I even told him it only had to be really short and I do em in less than 5 minutes) and even then he still wouldn't do it and he was like trembling in fear in doing something a 3rd year like him should be doing with his eyes closed. It's not like I was going to grade him or anything, I was just asking him to give me a lending hand. Then students wonder why us interns don't let them do more of the cool/fun stuff (you wanna do cool stuff? Earn it by helping us in the paperwork you can legally do).

Just another friendly reminder that you are still a medical student yourself and that your experiences in an entirely different educational structure do not really correspond to ours.

 

[SouthernSurgeon]

im a 4th year, and i still dont know what is going on. i feel so lost when taking care of the patient. especially since calls are made to the resident and the resident is the one who is usually updated on what's going on with the patient. the residents also put in the orders, since med students arent allowed to (would cause residents more of a headache if they did). when presenting the patient to the attending, i dont know what to present because i dont know what is importnat...

how can i be a better clinician...?? i want to give excellent care to patients and be prepared for my intern year. however, a lot of times, i feel so overwhelmed with what's going on with the patient that i get confused and sometimes mix the patients up...

thanks!

OP

1) Part of being a med student is feeling slightly "out of the loop" - you certainly should know by now that you are the last to know just about everything...as you say, the pages come to the residents, not you; the orders are written by the resident, not you; etc. But there are some things you can do - first of all, try to stay informed - ask your resident if anything is going on with your patients (or any other patients), check in on the patients throughout the day, go with the residents and help with new admissions/consults, etc. While you may not be writing the orders, think about what you would write and compare that to what actually gets written.

2) If you don't know what to present, then you are kind of behind the curve, honestly. But if you don't start figuring it out now, you are going to be in worse shape next year. You need to do 2 things - listen and ask. Listen to the other presentations (esp if you think some of your residents are particularly good), listen to how they organize and prioritize information. Ask for feedback; either your residents or your attending. Ask them how they would approach a particular patient or situation and how they would think through their problems.

Most importantly, keep trying to get better - don't let yourself get too bogged down in worrying about every little thing; your role right now is to learn - no one expects you to be perfect at this stage in the process.

 

[smq123]

Can't you just read the history chart and ask questions to the patient yourself?

What the OP is referring to is the stuff that the patients DON'T know.

The patients don't know that their potassium level is 6.3, and that they have t-wave changes. The residents DO know, though, because we get paged by the lab.

The patients don't know what time trauma surgery is taking them to the OR for their PEG/trach.

The patients don't know that nutrition decided to change their TPN mixture, or what time they're getting a PICC inserted.

This is, of course, ignoring all the many patients who are either demented, non-verbal, or ventilated and always sedated. This is assuming that all of your patients CAN answer your questions.

I suspect that you were misreading the OP's question.

 

[tfom08]

Just another friendly reminder that you are still a medical student yourself and that your experiences in an entirely different educational structure do not really correspond to ours.

LOL, for some reason this never gets old to me. Neither him answering questions with answers that are irrelevant to the experience in US training hospitals, nor you reminding him that is the case. I'm a simple person.

 

[SouthernSurgeon]

LOL, for some reason this never gets old to me. Neither him answering questions with answers that are irrelevant to the experience in US training hospitals, nor you reminding him that is the case. I'm a simple person.

I can't help myself...his attitude bugs the heck out of me

 

[Pinkertinkle]

LOL, for some reason this never gets old to me. Neither him answering questions with answers that are irrelevant to the experience in US training hospitals, nor you reminding him that is the case. I'm a simple person.

Isn't there some international sub forum he can post in?

 

[herpes]

thanks southernIM. you're right. I think if i try harder and put more effort into learning, then I could possibly improve... (hopefully). i guess i still have until july of next year to get better

 

[montessori2md]

I think you should talk to someone you both respect and trust at your hospital, if you don't feel better about this soon, and see they can help you feel more confident. That person could be an attending, an advisor, or even a peer, who can give you opportunities to practice in a safe environment.

 

[KeyzerSoze]

just another friendly reminder that you are still a medical student yourself and that your experiences in an entirely different educational structure do not really correspond to ours.

+10

 

[KeyzerSoze]

LOL, for some reason this never gets old to me. Neither him answering questions with answers that are irrelevant to the experience in US training hospitals, nor you reminding him that is the case. I'm a simple person.

Yep, it is one of the simple pleasures of life. I think vasca is a girl, though:

I wonder how come you didn't get the Tamiflu BEFORE getting symptoms?

I probably got exposed to it at work, but I never got sick. Maybe I'm going to go take a dip in the ocean today or something in a skimpy bikini. dunno. Good thing I didn't get sick 1 day before my vacations started, that would have sucked!

Or maybe he has an interesting fashion sense.

 

[Rendar5]

...correct me if I'm wrong, but aren't Vasca and the OP both at identical steps in the process? lol.

But yeah, to the OP, you're a 4th year, you need to step it up. If that means comining early, knowing the patient better than you know yourself, and studyingup on basic patient care management yourself in your spare time, then so be it. Your concern is not killing the patient, as the residents will be responsible for that. Your concern is learning treatment and management. You should already be skilled in the majority of differential diagnosis, history taking, note writing, and physical exam (with the exception of diseases and syndromes that are not classically taught in medical school such as concussions)

 

[herpes]

im worried i will never "get it." i know the basics but i dont really know how to "care" for the patient. there is a big difference between a med student and an intern... there much more to know the an H&P and a differential...I am talking about actual medical management...
i asked current residents about this, and they said they were just thrown in there Day 1 of intern year. basically, they were still "just a fourth year medical student that just graduated" so they didn't know much until they did it every day and got use to it. as a med student, you're so dependent on the resident that it's not really the real thing. most of 3rd and 4th year is spent just sitting around (for the majority of people)...oh well

 

[Rogue Synapse]

im worried i will never "get it."

Haha.




(it's your username combined with that first line)

 

[Doctor Bagel]

im worried i will never "get it." i know the basics but i dont really know how to "care" for the patient. there is a big difference between a med student and an intern... there much more to know the an H&P and a differential...I am talking about actual medical management...
i asked current residents about this, and they said they were just thrown in there Day 1 of intern year. basically, they were still "just a fourth year medical student that just graduated" so they didn't know much until they did it every day and got use to it. as a med student, you're so dependent on the resident that it's not really the real thing. most of 3rd and 4th year is spent just sitting around (for the majority of people)...oh well

Honestly, I think you just learn on your feet, and you won't really master medical management until it's on you. I think all of us 4th years are feeling a little incompetent right now and worrying about next year because we know the difference between us a new intern is pretty minimal. Certainly try to learn as much as you can right now, but I think maybe you don't need to be stressing quite as much as you are.

 

[Droopy Snoopy]

Your concern is not killing the patient, as the residents will be responsible for that.

 

[45408]

Honestly, I think you just learn on your feet, and you won't really master medical management until it's on you. I think all of us 4th years are feeling a little incompetent right now and worrying about next year because we know the difference between us a new intern is pretty minimal.

I thought that my two acting/sub-internships made a huge difference. Finishing the end of third year, I was in a few slow rotations, but I came into fourth year with some heavy hitters like my surgery sub-I and medicine sub-I right at the beginning. I felt like I was definitely keeping pace with the interns. Ironically though, the M4s doing their medicine sub-I have twice as much overnight call as the interns (Q4 vs Q8)...

I don't think I mastered medical management, obviously, but I think I got pretty good at handling an intermediate-difficulty work-up. I would definitely like to improve my cross-cover skills though...

 

[ucsfstudents]

It takes time. Just keep pushing yourself to take as much ownership of your patient as possible, and come up with plans for your patient (rather than waiting for your resident to tell you what to do). Don't just wing it. Read about your patient's illnesses, and management of all of their problems. It'll start to sink in with more practice and ownership. Knowing what's going on with the patient (pathophysiology, prognosis, lab interpretation, treatment options, imaging studies, etc. etc.) is important -- so try to work hard to master those. Don't worry, you're not alone. If your resident is first call, make sure to stay updated on every call that your resident gets on your patient. Also, check in on your patient, review labs, review images, review orders so that you understand what is going on.

 

[USArmyDoc]

I thought that my two acting/sub-internships made a huge difference. Finishing the end of third year, I was in a few slow rotations, but I came into fourth year with some heavy hitters like my surgery sub-I and medicine sub-I right at the beginning. I felt like I was definitely keeping pace with the interns. Ironically though, the M4s doing their medicine sub-I have twice as much overnight call as the interns (Q4 vs Q8)...

I don't think I mastered medical management, obviously, but I think I got pretty good at handling an intermediate-difficulty work-up. I would definitely like to improve my cross-cover skills though...

I agree with you here.....OP, all you need is an experience as a sub-intern that actually makes you the intern! I have friends who did rotations where they took the intern off the team and you were the intern. You put in orders, call in consults, get paged every 20 mins about diets!!! etc

This is happened to me. I was carrying so many patients I was struggling, but I had a great resident who sat me down to talk over my weak points. Ever since then, I learned to manage things quickly. After one embarrassing moment in the ER for taking to long doing an admission, I am able to do one real quick...lol

 

[ambulancedriver]

i'm not sure how you guys even as sub-I's were able to do all that. for example, carrying the pager is next to useless because half the calls require putting a simple order in, which you can't do, so inevitably you need to page the resident to put it in for you (or at least sign the order you put in). essentially you're a middle man that can be easily eliminated to speed up the process (i.e. nurse just pages resident directly).

try as hard as I did, essentially my sub-I was like my third year because of this. It was different only because I made it different by focusing on intern-type things (repleting lytes, calling in consults, figuring out insulin regimens, etc.)

how did you guys get around that problem to truly act like an intern?

 

[calvinNhobbes]

Did you not learn anything as a M3?
I felt like a rockstar as an M4. It was like being an M3 but I actually knew something. If you are even halfway competent the interns love you. M4 year was the easiest year of med school by far.

 

[DaveinDallas]

Honestly, I think you just learn on your feet, and you won't really master medical management until it's on you. I think all of us 4th years are feeling a little incompetent right now and worrying about next year because we know the difference between us a new intern is pretty minimal. Certainly try to learn as much as you can right now, but I think maybe you don't need to be stressing quite as much as you are.

F*((in-A Tweety, you got that right!!! I'm busting my ass to nail down and memorize dose regimens, make sure I stay on top of my drug reactions and learn as much of the real world stuff (you know, the things they DON'T emphasize and put aside for such relevant crap as histopathology of the appendix) as I can between now and July. I've missed a few simple things because the exhaustion of 3rd year is finally outrunning the adrenalin dump......

 

[DaveinDallas]

im a 4th year, and i still dont know what is going on. i feel so lost when taking care of the patient. especially since calls are made to the resident and the resident is the one who is usually updated on what's going on with the patient. the residents also put in the orders, since med students arent allowed to (would cause residents more of a headache if they did). when presenting the patient to the attending, i dont know what to present because i dont know what is importnat...

how can i be a better clinician...?? i want to give excellent care to patients and be prepared for my intern year. however, a lot of times, i feel so overwhelmed with what's going on with the patient that i get confused and sometimes mix the patients up...

thanks!

Sounds like you're sitting back, trying not to get in the way. Screw that - it's YOUR education and YOU will be on the line July 1. NOW is the time to screw it up in a safe environment.

Go talk to your chain of command and let them know that you want to start improving your abilities. Be open and honest with them (unless they're real douchebags, they'll be willing to help), grab one or two patients (start slowly) and get cracking. If you don't know how to take the chief complaint and H&P and consider a differential, grab ScutMonkey (the book) as it lists differentials for each presenting symptom/clinical sign. Wean yourself off the book asap. Then figure out which labs/studies to rule-in/rule-out different things and slowly work into treatments - go from 'Consider HTN meds' to 'Suggest starting MedX at Xmgs so many times a day' or whatever (you get the drift)......If you start now, there's no reason you couldn't have a high level of confidence by the end of the month. But you'll have to work hard....

But as other posters have said, take 'ownership' of YOUR education.....you're paying for it (or at least your parents are).....

One last thing: remember that you can get fired from a residency. Just because you land in one doesn't mean you're 'safe' for 3 years.......