I'm the problem resident and I'm afraid I'm going to lose my job

[xffan624]

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This is the first time I'm posting an actual thread, but I guess I need some support or something. I'm a 2nd year pediatric resident now and I've had struggles throughout my residency. Organization, communication issues, attention to detail etc. The program has been supportive and tried to help me by pairing me with seniors, but it doesn't seem to be helping. I've tried to do my best and improve my deficiencies, but I don't think I'm improving. My most recent eval in ED was pretty damning and basically questioned whether I belonged here. The rotation I am currently on has q4 call where we cover patients overnight. They don't trust me at night and have me paired with a senior. Even with this, there has been one issue with my phone not ringing when needed and another when the attending was underdosing the morphine for a patient in severe pain because she didn't really feel comfortable giving more and I gave an appropriate dose to manage his pain, but she was not aware and tried to give more morphine before realizing. I feel like I'm trying my best, but every time I mess up or something, it's a step backward and I'm not really making progress forward. I just wonder when their patience is going to run out and how I can ever graduate residency if they don't trust me by myself. It's mentally exhausting walking into residency daily with a feeling like I have a target on my back and makes me not even want to go work. At the same time, I see my fellow residents, compare myself to them, and wonder what I'm doing so wrong that I'm nowhere near their level. I'm embarrassed when I have a shadow senior and my other residents don't. OTOH, my most recent ITE scores were wonderful. I am well above average and have an excellent chance of passing the boards. That's about the only thing I have going for me right now.

I'm an older resident and this is the field I've chosen, but I'm wondering at what point I have to cut bait and call it a day and change to something I won't screw up at daily.

Any words of wisdom or support would be appreciated. Tough love too, but I'm not sure how effective it will be. I already feel like sh1t and think I'm crappiest resident in the world.

 

[feb14]

You say your program has by far been supportive which is something you won’t find everywhere.. since they have paired you with someone ( apparently a better resident-per their evaluation), I would suggest following what they do, learn from them and don’t be shy to ask for help from those residents.. see how they deal with things and learn.. you still have almost two years to graduate, time has not passed yet.. good luck!!

 

[mvenus929]

What specifically are your issues? The two examples you gave could happen to anyone and are only really a problem because you already have a target on your back. Are you not collecting thorough histories? Is your medical knowledge behind? Are you not able to see the nuances in different cases (I.e. fever in a baby at 2 weeks vs 6 weeks)? Are you missing important details in the chart in your prerounding?

 

[xffan624]

What specifically are your issues? The two examples you gave could happen to anyone and are only really a problem because you already have a target on your back.

Are you not collecting thorough histories? there are occasionally things specific attendings ask that I miss, , but for the most part, no.

Is your medical knowledge behind? I do great on the boards. We see up to 21 year olds so I had specifically a case hemorrhoids in a patient that I had identified, but I honestly I had never seen it before and I did not look up for treatments before talking to the attending.

Are you not able to see the nuances in different cases (I.e. fever in a baby at 2 weeks vs 6 weeks)? Are you missing important details in the chart in your prerounding?

Maybe, but not in specific case you provide. It's usually more subtle. Last night I noticed the patient had a history of macrocephaly (increasing) and mother had noticed bulging fontanelle so I made sure he got back to a room quickly. He was fine, but I thought it was still good to make sure he was evaluated quickly.

Other cases it's more of a subjective evaluation of sick vs well which I'm not sure I always get.

 

[Crayola227]

Do not give up unless you really feel peds or medicine at all, is not for you. What you describe, I'm not sure would be addressed by going to a different program or field. You are not expressing that you don't want to do peds as a field.

Have you been put on official probation? I'm surprised you haven't been. The fact that they think you are not doing well, making remediation efforts, AND have not probated you (assuming they haven't) are actually encouraging signs for a struggling resident, because probation is a necessary step towards termination, and rather than checking that box, they are trying to help you without doing so. This suggests to me they have a sincere desire to have you finish the program, especially since you struggled intern year but they helped you then, renewed and promoted you, and are helping you now.

All of this also suggests that they think you are actually remediatable, or why bother? At least it sounds like they're going to give an honest try.

That isn't to say you should get too comfortable. But being perpetually freaked out isn't going to help. Yes, they are watching you closely, but it looks like it isn't with an eye to "catch" you to terminate you.

Have you been brought before anyone like the Chief or PD to discuss your performance? If so, you know the cat is out of the bag as far as your struggles. Not everyone is actually effective at giving concrete strategies to a struggling resident, but to anyone that already knows you are struggling, you need to ask them for specific strategies to address where you are deficient. Or at least try to elicit what specifically you are struggling with from their view. That is the first step to improving.

Beyond validation, explaining the process of what happens when residents "get in trouble" and my own opinion on what is going on, without specifics I can't give you too much on improving specifically.

My post Things to do to shine in PGY-1 I've been told has been somewhat helpful to struggling residents, but it is geared more towards interns. However there's some organization, time management strategies that could help you.

 

[Crayola227]

Keep in mind, that since you describe a good knowledge base, and do not mention personality conflicts, professionalism/character issues (lying, late, shirking work, etc), there is a good chance you can be remediated with time and effort. Sounds like they are giving you the effort, so far you have the time. I have no idea if they would allow you to repeat the year if it came down to it, but I would hope so.

Keep your spirits up if you can. The battle is not lost. You cannot focus on your past mistakes, even if they were yesterday or an hour ago. You do need to look at them and consider how to not only not do the same thing again, but what to learn from it that will help you all around. Otherwise, do your best to put it behind you. Each day really is a new day.

The first thing the struggling resident needs to do, is deal with their feelings, the anxiety, the upset, the blow to confidence. You CANNOT improve if you don't get the negative self talk under control. Tap into your will to persevere. Do your best to divorce your sense of identity and self worth from your performance. The more you try to feel OK with yourself and dispassionate about your performance beyond what needs done, the better able you will be to problem solve.

The next thing is to reach out to those who support you, can help you, and identify what needs to be done. Easier said than done.

I don't care how "bad a job" you think you are doing. You can still be the HARDEST working resident in your program. The hardest working also tend to be the most liked. Don't underestimate what that can do to rally support not only to keep you, but help you too. It can also help you with that "target" on your back and the overall perception of you and your work.

Safe, fast, pleasant, in that order. But notice that pleasant is on the list. And you need to maximize that when you are struggling with the first two.

A PD told me that honesty and work ethic cannot be "remediated," but the hard working resident with good character almost always can in one way or another. The MD grad, by virtue of getting through to graduation, 99% of the time has what it takes under the right conditions to remediate to be a competent doc. I'm not saying that is always how it happens. But you have the raw material.

You CAN do this. I think your program thinks you can do this.

So be the first resident at work. Be one of the last to leave (understanding that you may have family, etc). On the topic of last to leave, keep in mind that you need to maximize your SLEEP as your number one self care.

How is your self care? Sleep, food, water. Basic and simple interventions that do LOADS for your brain, try to get them and the food/hydration while at work. I know peds you guys don't tend to wear the white coats and their pockets, but any appropriate coat that can hold a bottle of water and some snack bars is ideal, or keep that very close at hand in the workroom.

Never complain, never argue when a criticism is made of you. Always come off grateful. Unless you are already overwhelmed, offer to do whatever you can to take on more work that will get someone else home sooner (without violating hours, of course).

Being the hardest working, the kindest, the most anything positive you can be, can be something you can at least feel good about yourself, and help you get a sense of pride in that. Anything to counteract the negative in your heart, will poise you for concrete improvements.

I'm sure people have better advice, this is just my first thoughts on Improvement Foundation 101.

 

[ThoracicGuy]

This is the first time I'm posting an actual thread, but I guess I need some support or something.

First I want to acknowledge that you posted under your regular account rather than making a throwaway account. That takes a bunch of cojones. Second, if the program continues to work with you, then you owe it to them to do everything you can to continue to improve. Have you talked to some of the seniors that you trust to see if they can lay things out for you? What does the senior that shadows you say on your day to day performance? Third, have you checked yourself out with a family doc to make sure there aren't any underlying health issues that could be hindering you in any way? Likely a long shot, but you wouldn't want to miss it.

I wouldn't take it upon myself to just resign if I were in your situation. That is too much of a risk of not finishing and having the chance to practicing. If you switch to any other specialty, you'll have to start back in year 1 of training as I don't think anyone will accept a peds year as an intern year.

Good luck.

 

[Shinken]

ThiThe program has been supportive and tried to help me by pairing me with seniors, but it doesn't seem to be helping.

You should set up a meeting with your program director to discuss these concerns.

Tell your PD what's on your mind, how you're feeling every day, how you're struggling, etc. and ask the PD to come up with a more specific plan for you, that's their job (if they're being truly supportive). Also, resident wellness is a big deal nowadays. Let the PD know you dread going to work daily due to the way you feel.

For your PD to pair you with someone is OK, but you need to know exactly what they expect of you. You need a written remediation plan (I know you're not officially on probation, but you seem to be heading that way. You need to be proactive and avoid that).

Have your PD write down your expectations in terms of communication, detail, etc. That way you know what to do to correct your deficiencies, and you will have a guide as to how you're progressing (or not).

 

[MediCane2006]

Concur with the posters who have recommended a more concrete action plan. Being proactive about this buys a metric ton of goodwill from your faculty.

You need to write down what you feel are your top 5 deficiencies. Be concrete. "I have difficulty triaging severity of pathology", "I get overwhelmed and have a hard time prioritizing clinical tasks", "My knowledge base for endocrine and metabolic diseases is deficient", "I struggle with knowing when to call a senior vs handling something on my own". FYI this is very, very hard to do as it requires being brutally honest with your deficiencies. Review this with one or more of your supervising residents (this also sucks) and incorporate their feedback, but keep it to the top 5 bullet points rather than a laundry list. Then come up with a 3-6 month plan to address each one, with bullet points. "I will complete monthly oral examinations with faculty members on metabolic diseases", etc. Sit down with your program director once you have this drawn up. Explain to them that you know you are struggling, you have sought feedback from senior colleagues and identified 5 key areas where you need to improve. Get your PD's feedback on your plan, and then schedule monthly followup meetings with them.

Stepping back for a moment, obviously it's a possibility that you are just not cut out for pediatrics, but I would submit that that would be quite rare. More likely, you had some struggles early on (as we all do), that were never corrected and just snowballed. Once that happens and your confidence takes a hit (which is inevitable since we are all perfectionists and our own worst critics), it all starts spiraling from there. I have been in your shoes and it sucks. Imposter syndrome is a real thing, and situations like this only make it worse. The worst thing you can do, though, is be paralyzed by feelings of failure. I promise you, if you "can't cut it" in this field it will become apparent, but by taking a proactive approach you will ensure that no matter what happens, your faculty will be on your side and maximizing your chances of success.

Good luck and keep us posted!

 

[xffan624]

Thank y'all for your support, I really appreciate it. Honestly it feels good to get this stuff off my chest as I haven't really talked to many people about it. It's pretty embarrassing. I want to clarify some points. I am not on probation at least as far as I am aware. I have discussed at length these issues with my program director and I have a semi-annual review this month where I can express my stressors and maybe come up with a plan. I have been referred to EAP to these issues and been seen by them. I saw them a couple times, and would like to see a regular counselor which I am attempting now. Self-care wise, my extracurricular activities are pretty much what sustain me. I like to work out and I watch a lot of sports, live and TV. My parents don't live close and I'm not close to them regardless, but I try to see my sister regularly. I plan pretty nice vacations which are a big motivator for me.

Probably my biggest weakness is I don't like asking for feedback, but I know I have to. I try not to be defensive and take the feedback when it is actually given and make improvements on that.

 

[hallowmann]

...Probably my biggest weakness is I don't like asking for feedback, but I know I have to. I try not to be defensive and take the feedback when it is actually given and make improvements on that.

I think you've been given a lot of great advice here, so I'll try to be brief. I agree with others, that your program appears supportive, they have given expectations, and you seem to be struggling to meet them. As a result, you feel like giving up and are questioning whether or not you can do it.

We all question whether or not we can do it, whether we're "officially" struggling or not. Its the nature of the job. You can do it. You can improve, you just have to want to with a clear enough mind and plan to get it done. At very least, it seems like your program believes you can do it too, because they are taking big steps to remediate you.

You need a plan of attack as described by posters above. Identify your weaknesses and identify concrete ways to address each one. Within that should be the fact that you don't like asking for feedback. I hate asking for feedback, it mostly causes me anxiety and often when I'm receiving it I am quietly screaming in my own head to the point where I can't always process it. But I still ask for it, every time.

Feedback is one of the most useful things we have as trainees. Not only does it show us areas to improve, it gives us insight into what clinicians find to be important, it can reveal roots of problems that we didn't know how to solve, and to be blunt, it shows us what individual attendings actually care about (i.e. things to focus on when you interact with X attending again on rounds - attendings are different, their priorities are different, some times knowing the attending's preferences is the most important part of the process).

Also, with regards to some of the situations you described: I don't know if your program is the same as the one at my institution, but while rotating through Peds, one of the most important things was notifying the attending with even mundane info. If an attending is changing orders from home, you should FYI them when you change an order that will take effect overnight/before the AM rounds. Some attendings are really possessive of their patients (often for good reasons). More than on any other service, on Peds I was both told to FYI the attending frequently and I did it on my own more frequently.

The post is getting long, so I'll end it there. You'll get there, just keep working, stay motivated, and continue the counseling.

 

[mvenus929]

Maybe, but not in specific case you provide. It's usually more subtle. Last night I noticed the patient had a history of macrocephaly (increasing) and mother had noticed bulging fontanelle so I made sure he got back to a room quickly. He was fine, but I thought it was still good to make sure he was evaluated quickly.

Other cases it's more of a subjective evaluation of sick vs well which I'm not sure I always get.

You need to figure out what your problems are. This requires you to be honest with yourself. It's got to be more than just sick vs not sick, because they wouldn't have a senior shadowing you unless they were worried about your clinical abilities. You don't have to tell us what your deficiencies are (though, as someone who has gone through more probations from the admin side than I really care to admit, I'm happy to help if you want to PM me), but you need to be able to articulate what they are.

If you're doing great on the ITE, then it's likely more of an application of knowledge, in which case, running through cases or simulations might be to your benefit. Running through nuances between cases with your attendings might be beneficial too (like, if this one thing was different about this patient,how would we treat them differently?)

Talk to your PD and/or chiefs. They seem supportive, again based on the fact that you haven't been put on formal probation as of yet, so working out a concrete plan will help you long term.

 

[MediCane2006]

I think the most important thing to emphasize, in addition to all the good advice here, is that THIS IS OK. Doesn’t mean you’re a bad doctor. Doesn’t mean you are a bad person. Doesn’t mean people will think less of you.

Your faculty is on your side and wants you to succeed. Utilize them. Obviously, if this is not the field for you, they have a responsibility to help you realize that but short of very egregious deficiencies they should be able to help you get through.

I have a big post reflecting on my insecurities and difficulties in residency through the retrospectoscope of a happy physician, that i will get the nerve to post one of these days.
Anyway. Hang in there.

 

[calvnandhobbs68]

I think the above posters are giving a lot of the benefit of the doubt here. like most of these posts, OP's self disclosed "transgressions" appear to be rather minor and there's probably stuff going on that he/she doesn't really realize/understand as the real reason he/she is the "problem resident". Like most of these "I'm getting kicked out threads", the OP seems to be focusing on random things that could happen to anyone (who here hasn't had their pager or phone not go off or run out of battery by accident at some point in their careers?) and less on systemic problems.

You could be having trouble applying your book knowledge base to real life situations (which seems to be what you're implying with some of your examples).
You could be having trouble looking up things you don't know (ex. the hemorrhoid thing when you didn't have any idea what the treatment plan could be)
You could be going rogue and people aren't appreciating it (ex. giving a patient morphine without letting anyone know when apparently the attending was also ordering stuff overnight? Were you in the PICU or something that sounds like a weird situation...)
You could be consistently missing important details ("oh yeahhh that patient did have 2 fevers last night" or "oh right he did have a SBP of 150 last afternoon whoops")
You could have really crappy communication skills and rub people the wrong way (which you might not recognize yourself)
You could be rubbing ancillary staff the wrong way and they're complaining about you (happens to the best of us but if you're getting consistent complaints from nurses/techs/therapy/whatever, the program will get pissed at you about that too)
Along with various other possible problems.

All the people saying YOU should come up with a list of things you should fix, I have to disagree with. You should be asking OTHER PEOPLE what you need to fix. Probably shouldn't come up with any ideas yourself or you probably would have done that by now, a year and a half into things.

What do your evaluations say? What do your co-residents or seniors say? By this point, you've already realized you're ID'd as the "weak resident" so you might as well let people know you're trying to improve your game and ask what they think you could work on. Plus you're in peds which is already a bonus, everyone is going to be way nicer and more willing to help, less willing to bite your head off in general 😉.

 

[Crayola227]

I think the above posters are giving a lot of the benefit of the doubt here. like most of these posts, OP's self disclosed "transgressions" appear to be rather minor and there's probably stuff going on that he/she doesn't really realize/understand as the real reason he/she is the "problem resident". Like most of these "I'm getting kicked out threads", the OP seems to be focusing on random things that could happen to anyone (who here hasn't had their pager or phone not go off or run out of battery by accident at some point in their careers?) and less on systemic problems.

You could be having trouble applying your book knowledge base to real life situations (which seems to be what you're implying with some of your examples).
You could be having trouble looking up things you don't know (ex. the hemorrhoid thing when you didn't have any idea what the treatment plan could be)
You could be going rogue and people aren't appreciating it (ex. giving a patient morphine without letting anyone know when apparently the attending was also ordering stuff overnight? Were you in the PICU or something that sounds like a weird situation...)
You could be consistently missing important details ("oh yeahhh that patient did have 2 fevers last night" or "oh right he did have a SBP of 150 last afternoon whoops")
You could have really crappy communication skills and rub people the wrong way (which you might not recognize yourself)
You could be rubbing ancillary staff the wrong way and they're complaining about you (happens to the best of us but if you're getting consistent complaints from nurses/techs/therapy/whatever, the program will get pissed at you about that too)
Along with various other possible problems.

All the people saying YOU should come up with a list of things you should fix, I have to disagree with. You should be asking OTHER PEOPLE what you need to fix. Probably shouldn't come up with any ideas yourself or you probably would have done that by now, a year and a half into things.

What do your evaluations say? What do your co-residents or seniors say? By this point, you've already realized you're ID'd as the "weak resident" so you might as well let people know you're trying to improve your game and ask what they think you could work on. Plus you're in peds which is already a bonus, everyone is going to be way nicer and more willing to help, less willing to bite your head off in general 😉.

I looked over every single post above, and every person offering advice said the OP needs to reach out to figure out what to do. I guess it might not have been made clear that the way the OP makes a list of what to improve, is going to anyone around them who can help.

I think you did a nice job of explaining more what could be problems a struggling resident may not be recognizing, and emphasizing how important it is that they uncover from OTHERS what is wrong.

I talked to my friend a peds senior, and sadly getting feedback, even when you practically beg for it, in real time, can be extremely difficult to get in peds. There can be a real conflict avoidance mindset, and that could actually explain a lot here. Fair point that any feedback is less likely to be phrased in a soul-crushing manner.

That said, this is why not providing feedback, especially when a resident is struggling, especially when they ask, is so damaging. However we don't know how the feedback is being given or received.

I agree that OP's examples show some lack of insight and also could very well represent all that you mentioned. Unfortunately, besides a buck up on how to deal with the negative feelings that are certainly contributing to holding them back, and strategies for eliciting help from the program (thank you Calvn), this WILL come down to how the program and resident are interfacing.

Personally, I found that not everyone in a training program can even articulate what you are doing wrong, beyond the fact you're doing it wrong. Even when it's laid out for you specifics, I've then found that many have no clue on teaching you concrete strategies for improving those weaknesses. Knowledge base is easiest.

We all seem to agree that the program is supportive, OP needs to leverage that in seeking and taking feedback, the most important thing they can do. That and keep the negative feelings from being crippling.

 

[calvnandhobbs68]

I looked over every single post above, and every person offering advice said the OP needs to reach out to figure out what to do. I guess it might not have been made clear that the way the OP makes a list of what to improve, is going to anyone around them who can help.

I think you did a nice job of explaining more what could be problems a struggling resident may not be recognizing, and emphasizing how important it is that they uncover from OTHERS what is wrong.

I talked to my friend a peds senior, and sadly getting feedback, even when you practically beg for it, in real time, can be extremely difficult to get in peds. There can be a real conflict avoidance mindset, and that could actually explain a lot here. Fair point that any feedback is less likely to be phrased in a soul-crushing manner.

That said, this is why not providing feedback, especially when a resident is struggling, especially when they ask, is so damaging. However we don't know how the feedback is being given or received.

I agree that OP's examples show some lack of insight and also could very well represent all that you mentioned. Unfortunately, besides a buck up on how to deal with the negative feelings that are certainly contributing to holding them back, and strategies for eliciting help from the program (thank you Calvn), this WILL come down to how the program and resident are interfacing.

Personally, I found that not everyone in a training program can even articulate what you are doing wrong, beyond the fact you're doing it wrong. Even when it's laid out for you specifics, I've then found that many have no clue on teaching you concrete strategies for improving those weaknesses. Knowledge base is easiest.

We all seem to agree that the program is supportive, OP needs to leverage that in seeking and taking feedback, the most important thing they can do. That and keep the negative feelings from being crippling.

I agree that peds people can be hard to get feedback from sometimes because they're so nice and unwilling to say negative things about others (esp other residents). However, OP I think if you approach it as "I want you to be truly honest with me, don't pull any punches, give it to me straight I'm actually trying to figure out what I'm getting wrong and what I can improve on"....you should be able to eke out a few honest answers from people. Let them know you're not going to get offended no matter what they say ahead of times too, you want them to let you have it.

Because that's what you want right now. You want your co-residents and seniors to let you have it, beat you down with all the negative feedback they have to say about you and then list it out and plan out a plan of attack. You should be extremely pro-active right now. You should be saying to your seniors that they're having you work with "Hey, I know I'm getting paired with a senior for a reason. Here's what I'm working to improve on this month. I'm going to come back to you every week and ask if you think I'm improving at all with this skill or, if I'm not, if there's another approach you think I could try."

You can do it. You're in a field where they're not gonna toss you out the door and terminate you next month. Also, if you make a obvious effort that you know you've been weaker, you're seeking out feedback and making it obvious you're trying to get better (by essentially screaming in everyone's face you work with that you're working to improve haha) people will respect that as well. People respect pro-activity in medicine.

 

[deleted480308]

Are you getting there 30min earlier than you used to before this so you can “extra preround” and chart dive and really know your patients?

 

[BigRedBeta]

I think you are either overselling your difficulties or underselling your examples.

As others have said you need to be honest with yourself about where your difficulties are. I will say that once you get labeled as the problem resident, there becomes a vicious cycle where you get even more scrutiny and any misstep, no matter how tiny, gets magnified in a way that your co-residents don't have to worry about. What's worse is that these tiny misdeeds can end up being the focus of feedback sessions, derailing discussions about bigger issues that if you can fix, will actually lead to meaningful, sustainable change.

Residents struggle for any number of reasons, but everything can be grouped into big buckets:

Knowledge Base: Simply you don't know enough, don't pick up things quickly, or are slow to learn from your mistakes

Application/interpretation: you actually know what and how things work, but in going from books to your brain to bedside, something gets lost in translation. Maybe you second guess yourself, maybe you get lost in all the details you do know, maybe you're way too focused on details that don't matter (I see this a lot with people who are way to focused on etiologies - ie if I ask for a cause of hypoxemia, they give me an answer like RSV bronchiolitis without realizing it's a sub-sub-sub category of a diffusion gradient abnormality of which there are dozens of causes)

Work ethic/efficiency: Do you forget things? Do you not show up? Does it take you 45 minutes to take a history when your co-residents can do it in 15? Are you constantly trying to leave early and so are sloppy with your work? Does trying to make your notes perfect get in the way of doing actual work (writing orders, talking to consults, getting discharges done)?

Personality Issues/Professionalism: Are you hard to work with? Do you come off as arrogant or belittling? Are you a poor team player?

Poor fit with residency program: Are you someone who learns by doing but ended up in a place with lower clinical volume that everyone talks about making sure you have time to read? Or are you a reader who is at a place where burning through patients is considered the best way to learn?

These big buckets go from easiest to hardest to fix in my mind, but somethings in the first 3 categories can be really challenging to remedy.
You need to be honest with yourself about where things aren't working.

In general though, some things that I feel like almost all interns and new 2nd years need to focus on:
1) Say "I don't know, but I will find out for you" more often. It's okay to not have a piece of data or the right answer. What's not ok is not finding out.
2) Give up on crafting the perfect note - hospitalized kids change and the plan that goes in at 830 in the morning may not be what the child needs at 930am
3) Think bigger picture - many students and interns that haven't made the jump in their progress are in a mindset of "If I can just see XYZ condition then I'll know how to treat it". The problem is that even if you memorize the top 250 pediatric diagnoses and their treatments, you're SOL when a patient with diagnosis #277 sits down in front of you. So focus instead on what their symptoms are and how you treat those and then work backwards through the physiology.
4) Ask for help, but have a plan to suggest
5) Write down a concise but informative 2 liner on every patient, every time, until doing so becomes second nature. If you can rattle off in the span of 15 seconds a summary that is accurate, relevant, and paints 95% of the picture for your colleagues and attendings, then it becomes obvious that you know your patient. The frame work is: "This is an ## year old patient with past medical history of XYZ and ABC who presents with DEF primary problem, for which we are doing M, N, O, and P for. Other major issues are 1,2,3, but on the whole the patient is getting better/worse."

If you are a jerk to people, keep in mind that if people like you but you're not good at your job, you usually get to keep it. Likewise if you are insufferable, but an excellent physician, people will put up with you...but if you are both bad at your job and a pain to be around, there's no escaping your dismissal.

If you chose a poor fit for residency, unfortunately you are going to have to tough it out. But you can always go to your PD and explain how you are feeling about fit and see how they might be able to help you.

 

[xffan624]

Just wanted to update y'all on what's going and clarify things. My deficiencies as a resident are obviously much more than I have posted here. Needless to say, my program doesn't feel that I am at the level that a 2nd year resident should be based on the feedback given.

I have met with my PD and now will be on probation. They will suggest a remediation plan shortly. They are still supportive and want me to finish this program, but they have to do what they have to do. I I blankly asked the PD whether I could lose my job and she said that for most residents in this situation they are able to finish, but, of course, there are no guarantees. It's honestly like pulling the bandaid off for me. I know where I stand. I obviously want to improve. I switched to a new rotation and I'm trying to work hard and build good relationships from the start to not have to play catch up. I am trying to ask questions but still try to find the answers on my own when possible. I survived my first long call of 28 hours and a little bit more and got good feedback from the fellow.

 

[Crayola227]

Definitely want to be asking feedback on a daily basis to those who are willing to engage in that process with you. Equally important is how you receive that feedback in the moment.

Good luck.

 

[UKEMdoc]

I’ve never seen someone with insight get kicked out of training. I might be in a different country but being a doctor is being a doctor.

You’ve got people there who want to help you.
Looking at your post I’ve got a gut feeling that you care about your patients and your colleagues.

My first question is how are you?
My second is no, really how are you?
Moderate-severe depression is the most common reason for good people turning bad. Does your program have counselling? Check your PDP/burnout score.

I’d hesitate about overthinking things. Get honest feedback from 3 or 4 people in the program including the best nurse you work with. Discuss it with someone. Don’t lose sleep memorising a textbook - they want calm clinical decisions not a walking encyclopaedia.

Have you done many sim sessions? Get videoed seeing a patient, managing them and presenting them to a senior.

Good luck, you’ll get there and when you’re an attending remember to help out that resident who is working hard but just hasn’t got there yet.

 

[UKEMdoc]

Bumping to check how the OP is.

I’ve been thinking about your situation. It’s very difficult to please your seniors or perform well when your triple guessing every move.
What I want from my resident is someone who cares and I can rely on to ensure that when I come in the next morning there hasn’t been a disaster I wasn’t aware of.

 

[xffan624]

I can't post full details in order to remain anonymous. Things haven't gotten better. I am undergoing a return to work process due to an unfounded suggestion of substance abuse. They are still supportive but after this finally clears and I go to back to work, I'm not sure whether I want to stay.

Sent from my XT1650 using SDN mobile

 

[NotAProgDirector]

Regarding substance issues, as a PD I have occasionally had residents tested to make sure that all was OK. Even if my prior prob is low, it's not a problem I want to miss. So instead of an "unfounded suggestion", it might simply be "caution and concern". But obviously I don't know the details. I know it sucks and feels like people may have "accused you of drug problems", but it's something we just don't want to miss.

 

[Crayola227]

I can't post full details in order to remain anonymous. Things haven't gotten better. I am undergoing a return to work process due to an unfounded suggestion of substance abuse. They are still supportive but after this finally clears and I go to back to work, I'm not sure whether I want to stay.

Sent from my XT1650 using SDN mobile

I understand not wanting to stay because, well, residency sucks enough as it is when you're not even dealing with what you're going through now. I suggest that you consider what you might do if you choose not to stay in your program. I've found SDN helpful in this regard.

It's not clear to me what exactly the program's intentions towards you are, but if you think there is a chance they are acting more out of concern for training you than for terminating you, that you give them the benefit of the doubt.

 

[UKEMdoc]

Hang in there. It sounds like the program want to keep you so they must see something in you.
Screening for substance abuse shouldn't be a problem, negative urine sample and normal LFTs should be all you need. If you don't have those then you need to sit down with a professional tomorrow morning.

You managed to get into medical school (which is really difficult) and pass medical school (which is moderately difficult) so you are in the top 5% of the population for intelligence/talent etc. This means somethings going on with you, and whatever it is should be fixable. The training scheme is there to teach and support people. You deserve to be supported and taught.

Have a proper psych evaluation by a psychiatrist with a good reputation for looking after doctors. See an educational psychologist and get screened for the normal things and get them to look at how you interact and how you learn. Your hospital should have some sort of Occupational Medicine department, get in and see the most respected doctor there and listen to them.

Have you looked into mentorship? See if they can give you a mentor from a different department who can sit and talk to you.

I've experience supporting trainees in your position and I've got to say as an educator it's a wonderful feeling when you help them over the hump, watch them fly and complete their training.

 

[Crayola227]

I would be sure whatever psychiatric support you get is private, outside your hospital system and its EHR, and you do NOT mention it to your program at this point. This is not medical or psychiatric advice, I do not mean to discourage anyone from getting appropriate care, this is just career advice.

 

[Gfliptastic]

As someone who was scrutinized closely, constantly on the verge of remediation for most of intern year, I have an idea of what you are experiencing. Everyone was on me. My resident, attending, Chiefs, faculty - reading my notes, "stopping by" when AM rounds happened to hear me present. All of that can be difficult. Particularly when you have peers performing similarly and not being monitored. And there is some inherent hostility to all of that. Being known as the intern who is not up to snuff.

For me, it was a blend of both things. My ITE's were sub par and then I also had what many have already described as triaging problems. It did not matter that my Step scores were good, it wasn't translating into being a good intern. What I learned was to become repetitive, borderline OCD. From sign out from night float, rounding, writing notes - how I wrote my notes, checked labs, talked to nurses, wrote sign out notes, signed out, etc. I did all of it the same. Super repetitive. Like a check list. If it's good enough for the airline industry, it would work for me. Once you are almost robotic w/ all of that, you can focus on the importance of triaging. Patient R w/ the 3 bloody BM's needs assessment and recommendations/treatment before Patient L who you gave a laxative who finally had a BM.

As for what is inherent hostility (in your working environment), I found it motivating to be known as one of the worst residents. It became my mission to prove people wrong. Which wasn't easy nor did it happen overnight. But by the time I was a PGY3, EVERYONE wanted to work w/ me. The intensivists, specialists, gen med attendings, the new interns. When I was night float, instead of trepidation, the comments would be: "Oh thank goodness YOU are on tonight!!" Turning haters into fans is super gratifying. When the PD tells you: "Dr. U has never written such favorable comments on any evaluation except yours so far"

TLDR; version - become highly repetitive in the things you are supposed to do, so that you begin to notice when you miss something, and if the environment is hostile towards you because of your current poor performance, it can and should be motivation to change those against you into your biggest fans

 

[ThoracicGuy]

As someone who was scrutinized closely, constantly on the verge of remediation for most of intern year, I have an idea of what you are experiencing. Everyone was on me. My resident, attending, Chiefs, faculty - reading my notes, "stopping by" when AM rounds happened to hear me present. All of that can be difficult. Particularly when you have peers performing similarly and not being monitored. And there is some inherent hostility to all of that. Being known as the intern who is not up to snuff.

For me, it was a blend of both things. My ITE's were sub par and then I also had what many have already described as triaging problems. It did not matter that my Step scores were good, it wasn't translating into being a good intern. What I learned was to become repetitive, borderline OCD. From sign out from night float, rounding, writing notes - how I wrote my notes, checked labs, talked to nurses, wrote sign out notes, signed out, etc. I did all of it the same. Super repetitive. Like a check list. If it's good enough for the airline industry, it would work for me. Once you are almost robotic w/ all of that, you can focus on the importance of triaging. Patient R w/ the 3 bloody BM's needs assessment and recommendations/treatment before Patient L who you gave a laxative who finally had a BM.

As for what is inherent hostility (in your working environment), I found it motivating to be known as one of the worst residents. It became my mission to prove people wrong. Which wasn't easy nor did it happen overnight. But by the time I was a PGY3, EVERYONE wanted to work w/ me. The intensivists, specialists, gen med attendings, the new interns. When I was night float, instead of trepidation, the comments would be: "Oh thank goodness YOU are on tonight!!" Turning haters into fans is super gratifying. When the PD tells you: "Dr. U has never written such favorable comments on any evaluation except yours so far"

TLDR; version - become highly repetitive in the things you are supposed to do, so that you begin to notice when you miss something, and if the environment is hostile towards you because of your current poor performance, it can and should be motivation to change those against you into your biggest fans

Great post here with lots of good advice for the OP.

 

[UKEMdoc]

Agree with above ++
You aren't the first.
You won't be the last.
What we need is some sort of physicians anonymous group. I know other websites have a closed, confidential "couch" where people can discuss this sort of thing. One of the most empowering bits of it are being able to go back through threads and see people who've been through exactly the same thing.
The British Medical Association runs a confidential phone counselling service - do you have anything similar?
A good psychiatrist will write less than five words on an EHR when seeing a colleague.