Is it me or is it them?

[Olliver]

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I'm a PGY1 in emergency medicine and I need some advice. I know I've only been a resident for three months, but so far I hate it. I'm trying to figure out what the problem is and what to do. There are too many possibilities and I'm having trouble sorting through them. How do I know if it's me or them?

1) Am I depressed? I dont think so. If someone asked how i feel, I'm more stressed and tired all the time, not sad. I don't cry, I don't wish I was dead, I don't feel like life isn't worth living, I don't feel excessively guilty. I do feel like I don't want to get out of bed or do anything, but mainly I think I'm just exhausted and stressed like most residents are.

2) Am I in the right specialty but the wrong program? I'm at an intense county program, and I wonder if I'd be happier in a smaller or community program. I always feel like I can't keep up, and people are always pushing me to do things faster, see more patients. I feel like I'm dropping the ball on the patients I already have picked up beacuse I'm already stretched too thin. I didn't realize how strong that pressure would be because as a medical student, they didn't care how many patients we saw per hour. Now they do. The patients we see are tough too, inner city, drug addicts, etc. I'm proud to take care of people that no one else wants to help, but maybe it's too stressful for me to handle it.

3) Am I in the wrong specialty? I love emergency medicine as a field, but I wonder if I would be happier in a slower paced specialty like family med. The family residents at my hospital seem a lot happier and more relaxed, even the PGY1s. I don't mean to suggest that family med is easy, but I think at least in FM people have time to stop and think about things once in a while instead of rushing around like crazy the whole time. They have time to eat lunch. They aren't constantly changing the hours they work and trying to adjust to a new schedule.

4) Am I having normal new resident doubts? Maybe I'm still too early in residency to know if I can adjust eventually. When do you go from still tryhing to get adjusted to knowing that you're in the wrong place? How do I know if I'm there yet or not?

5) Should I do clinical medicine at all? Sometimes I feel like I would be happiest if I did something with less patient contact, like pathology. But I don't know if I really don't want to see patients or I'm just burned out right now.

6) Something else I haven't thought of? Some combination of the above?

Thanks if you've read through this whole long post, and any advice, including telling me to suck it up or whatever is welcome.

 

[colbgw02]

My vote is for 3, 4, or both.

My understanding of an EM physician's skillset is that it includes an ability to handle a large number of patients with widely varying problems simultaneously. If that is a weak point for you, then perhaps you won't be successful in EM.

Still, it's only mid-September. Everyone has a steep learning curve in the first few months of internship. Efficiency can be, and often is, learned, particularly within a certain EMR and/or hospital setting. Not knowing anything else about you, I'd say it's too early to second guess your career choice. If you don't feel like you've significantly progressed six months from now, then re-evaluate. In the meantime, keep your head down and keep working.

 

[beanbean]

As a new intern you should be focused on learning to diagnose and treat your patients and not to "move the meat." Efficiency and patients per hour should be taken on after you learn the basics. However, if you are lagging behind the other interns there maybe reason for concern.

Have you talked to any of your co-residents or co-interns? Your Program Director?

Residency is very stressful not matter which field you choose. It is normal to question your own sanity for choosing medicine while under such intess stress. Remember the grass is not always greenner in another program or another field, but if you are truly unhappy where you are start investigating your options now.

Best of luck to you whatever the future holds!

 

[Paddington]

Sounds like you picked the wrong specialty and the wrong program.

 

[Janedoedoctor]

I vote 2 or 4.
You don't seem to hate the work itself you just have a problem with being pressured to 'move the meat'.
At this point, you should not be comparing your efficiency to that of more experienced people. You need to learn the very basics of medicine and that takes time. Every single thing you do, you'll be able to do it at least 50% faster and more efficient in a year.
Make an honest comparison between yourself and other interns. If you are significantly slower there MIGHT be a problem, but even then you should give yourself more time (at least a year) to get more comfortable/experienced before you decide to change specialties.
Are there any attendings you feel comfortable with? If yes, have a talk with one of them to find out if they find you abnormally slow. I'm betting they won't.

 

[Law2Doc]

Sounds like you picked the wrong specialty and the wrong program.

Yeah, go with 2, 3, 4 or some combo.

 

[tkim]

#1 Rule of thumb is you should be seeing/dispo one pt/hr for every year of residency that you completed. You just started. Cut yourself a break. If you can see/dispo 1 pt/hr now, you are doing fine, despite anyone's pressure to 'move the meat'. Moving the meat comes with time.

#2 It's your intern year.

#3 You're not depressed. Just stressed.

 

[Olliver]

Thanks to everyone who responded. It seems like the consensus is that I need to give it more time, which I was thinking too.

beanbean, no I haven't talked about this to my co-residents or co-interns or program director. It's some of the senior residents who are pressuring me the most and I don't think they would be very sympathetic. I did some shifts with the program director and associate program director, and neither of them said anything about me lagging behind other interns. But I'm not sure if they would volunteer that information without me asking. I also dont know how the program director would take it if he knew I'm questioning my specialty or program, and for sure I don't want it to get back to him second-hand because other residents are gossiping about it.

Janedoedoctor, I asked one attending if he thought I was too slow and he didn't seem very concerned about it. I got feedback from another attending about being slow, but he didn't say it was abnormal. What he said is that sometimes i spend too much time talking to patients and that getting in and out of rooms faster is something I should work on. I don't keep track of how many patients other people are seeing, but I think I probably am slower than a lot of the other interns based on what I overhear people saying about how many patients they saw. I don't know if that counts as significantly slower or not.

tkim, I'm not quite averaging one patient per hour but I'm usually close, maybe one or two patients short of that on most shifts. That doesn't count the active patients signed out to me by off-service residents who I still have to dispo.

 

[lowbudget]

I'm going with #1. It's probably true that you're doing well at work. And it's probably true that your job performance is on track for someone at this point in their training plus/minus some variation between residents. We feel stressed when we haven't adapted or coped with the stressors placed in front of us. Well, in this line of work (medicine), the stressors don't go away. *Everyone* in every specialty is moving the meat: primary care, surgery, psychiatry, what have you.

You could give it time, you could talk to other residents, you could talk to your PD... but why bother trying to figure this thing out yourself? You've got plenty to do, why are you trying to diagnose yourself? Go see a professional and have them tell you that you're normal or having problems as expected or need more work in recognizing/uncovering why you're having a difficult time adapting/coping to stressors and then do it. You're a doctor to your patients. There's no shame and no harm in being a patient and have other people do the heavy lifting.

Most universities have a student health and counseling and they're free. If not, see a primary care physician, a psychologist, or psychiatrist and have it covered under your insurance. I mean, I guess you can talk to your PD or other residents... but you're not their patient and they're not your doctor, which means they don't work for you.

Besides, trying to solve #2-6 is super involved and may not be the problem to begin with. Start with a diagnosis, not a self-diagnosis, but have someone evaluate you first. What you'll find is that sometimes having a 3rd party, not involved in your daily life, offer fresh objective perspective and walking you through it is really all you need.

 

[nitemagi]

If I went with strict dsm criteria I'd ask -- Are you depressed, or do you not enjoy activities you normally enjoy?

I think the more appropriate question for you is --
Do you have a goal you're trying to pursue that you feel is impossible to attain, and is impossible to give up?

This is a whole other avenue of environmental causes of a certain type of depression. And in some ways it seems applicable to your situation. Being a new resident doing a good job or getting to the point of proficiency seems impossible. So in a way depression is an expected outcome, to a degree. The thing to recognize in this situation, though, is that the goal really isn't impossible. It's just you can't see at the moment how you're going to get from A to B. But you will. Talk with colleagues. If you need to, talk with a therapist. Figure out how to get whatever you need to get to your goal. Small steps. And pace yourself.

 

[Olliver]

lowbudget, we do have access to free counseling. I don't know how useful it is for residents specifically, but I can look into it. Thanks.

nightmagi, no, I don't think my goal is impossible to attain eventually. I guess I feel like I'm being expected to do more than I'm capable of right now. It's a little disheartening to feel like I'm trying my best and have the senior residents telling me to try harder. If i was slacking off, I would understand completely why they would tell me to work harder. But it seems like the main way they want me to try harder is by working faster. When I try to work faster, I start losing track of things and they get annoyed with me for that too.

Now that I'm thinking about this, it seems like the pressure is mostly from the seniors, not the attendings. It's usually a lot less stressful when I'm working one-on-one with an attending versus when I'm working with a senior. Of course there are a few attendings who are stressful to work wtih too, but most of them seem more understanding than the seniors are.

 

[Rendar5]

I don't know what your seniors are like there, but for me I got told to move faster by seniors a lot and it wasn't because I was slow at the time, it was because they were reminding me that i'm not a medical student and I don't have the luxury of spending 30 minutes on an H&P with someone. As an intern, that is the only place you should be looking to improve your efficiency at this point. you can get your chest pains down to a 5 minute H&P, your abdominal pains down to a 15 minute H&P (if you have to do a pelvic exam), etc.

Your goal should be 1 pt/hr for now.

 

[lowbudget]

lowbudget, we do have access to free counseling. I don't know how useful it is for residents specifically, but I can look into it. Thanks.

Good. By the way, I need to clarify when I said I think I would go with #1. I don't know if you have depression or not, but that's not what I thought you have. I think you have something else, so, make your way to free counseling. You'll find it more useful than you think.

 

[MSmentor018]

everyones' got great input but I am wondering....
1. what brought you into EM?
2. was this program your 1st choice? what did you like about it?

I am an EM resident and I couldn't imagine hating it so i am really intrigued about your post. every person fits differently in a program, some programs (residents) just don't fit with them. obviously stress is an issue and as an intern, I am sure it's there but it shouldn't be so overwhelming that makes you want to leave.....feel free to PM

 

[Olliver]

Rendar5, that makes sense. I didn't look at it that way because they always put it in terms of how the waiting room is filling up and I need to get done faster so we can see the new patients sooner. But maybe you're right about their motivation for pushing so hard. I have been trying to get through my H&Ps faster and I will keep working on that.

lowbudget, I dont think I'm depressed either. Like I said before, it's more that I'm exhausted and maybe a little burned out.

MSmentor018, I went into emergency med because I had an amazing med school rotation experience. It was my favorite rotation by far. I stayed at my home program for residency and it was my top choice. My experience as a resident is nothing like my experience as a med student. I know I should expect that on some level because I'm not a med student anymore, but the change was more extreme than I was prepared for. When I first started I felt like leaving residency every day. Now there are some days where I feel like it's not so bad, but I'm still always counting down to my next day off. That's what makes me think I might have made a mistake by doing emergency med or at least doing it at this program. If it matters, I never felt like that as a med student.

 

[Arcan57]

MSmentor018, I went into emergency med because I had an amazing med school rotation experience. It was my favorite rotation by far. I stayed at my home program for residency and it was my top choice. My experience as a resident is nothing like my experience as a med student. I know I should expect that on some level because I'm not a med student anymore, but the change was more extreme than I was prepared for. When I first started I felt like leaving residency every day. Now there are some days where I feel like it's not so bad, but I'm still always counting down to my next day off. That's what makes me think I might have made a mistake by doing emergency med or at least doing it at this program. If it matters, I never felt like that as a med student.

There are few med student rotations that do an accurate job of simulating the experience of being an emergency physician. The pick up one patient, dispo the patient, pick up the next patient combined with getting pulled into every cool procedure, case, etc. makes EM a fun rotation for those that can handle the hours and patient population. The essence of EM is staying cool under extreme stress and maintaining an appropriate economy of work-up. If you weren't seeing 3-4 patients at a times as a student, then you probably had no idea what you were getting into as a resident. The pressure from the waiting room and the need to get patients dispositioned so nobody is dying in the waiting room rewards a certain type of intelligence. I've seen some very smart interns that did poorly in EM because they had a lower tolerance for uncertainty and spent more time debating options in the face of insufficient data.

That being said I've seen plenty of interns that struggled with the uncertainty and time pressure that went on to become good residents and stellar attendings. Looking forward to the next day off and being tired are almost universal experiences for EM interns, especially early in the year. The calm and decisiveness needed are learned skills, and it can be difficult to determine this early if they're skills that are just going to take longer to develop or if you don't have the capacity to develop them.

If it makes you feel any better, it's likely that the fastest, most decisive intern in your class is making mistakes left and right and will get taken to the woodshed to get some of their arrogance beaten out of them.

 

[Olliver]

Arcan57, you described what I was trying to say about the difference between being a med student and a resident perfectly. Thank you.

It seems like I'm back to it being too early to know whether I can be successful in emergency med. I'm going to at laest give it a few more months before thinking about making any changes in program or specialty. Thanks again for all the responses. it really helped a lot.

 

[rachmoninov3]

It sounds like you're in a better spot Olliver, but perhaps just a few more bits of 'wisdom' from random strangers on the net:

1. You are not alone. As a FM intern I constantly doubt myself, I constantly think that I must be the worst intern in history, and I swear one night on OB I went to the chapel to pray that I didn't hurt any more women that night🙁

2. Like it or not, our paychecks mean that the programs are no longer trying to kiss up to us so that we rank them highly. Gone are the days of surgeons tell us "you could be my first assist any day!" That has been replaced by "how long has it been since you've been in the OR?!"

3. As strange as this may be, this is normal. Sick, twisted, and maybe even perverted, but still normal. Buckle up, hold on tight, and pray that the year is over relatively quickly.

 

[Olliver]

rachmoninov3, thanks for sharing. It does help to know that it's not just me who feels this way. For what it's worth, I doubt that you're the worst intern in history. Also, I wanted to say to your second point that I don't feel at all like my program hasn't treated me well. Some of the posts I have read on SDN make it sound like certain programs are out to get certain residents, and I have never felt like that. The tough love can be very stressful sometimes, but it's not mean-spirited, and it's not like I'm being singled out. I can't even imagine how awful that situation would be.

 

[belle54321]

Although you may not be depressed, I don't think seeing a counselor or therapist is not a bad idea. It will give you the opportunity to discuss your feelings with someone who is objective. It will help you really think through what exactly is the issue here.

 

[Olliver]

I wanted to update this thread since so many of you were nice enough to give me advice five months ago. I think the problem was that this program isn't the best fit for me for several reasons. But I'm liking it better, and I'm going to stick it out.

 

[rachmoninov3]

I wanted to update this thread since so many of you were nice enough to give me advice five months ago. I think the problem was that this program isn't the best fit for me for several reasons. But I'm liking it better, and I'm going to stick it out.

I'm glad to hear you're doing better. I too, feel much the same. I am still incredably homesick, and still have difficulty with the idea that I had to scramble into this residency. This makes it difficult because whenever something doesn't go right, or I'm not being challenged I always question the strength of my program, even though that may not be the case. In fact, we're the first in the state to achieve level III PCMH recognition.

However, things are moving along quickly, I don't exactly know what has happened, but I know I'm much closer to being a doctor than I was 8 months ago. I've passed step III, and I know that in a few months I will be able to apply for a license. Also, with all the mistakes that I make as an intern, I am glad to not be around friends while I'm being docterized.

Hang in there, 2015 is coming up fast!