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It's just not clicking

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SD2525

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Hey everyone,

I am a first year family medicine resident and I am currently in my third block of the wards. I just feel like nothing is clicking. Like I don't see the big picture. I see my coworkers and they all seem to be getting everything and it seems to be coming so easy to them. All I write notes all day long (admissions, progress notes, discharges), and my entire day revolves around making sure I finish all of my notes before we round with my attending. I feel stupid and unconfident (I admit I don't have a strong amount of medical knowledge) and it is showing.

What am I doing wrong? Why isn't it clicking???
 

Powerplant1

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take a step back and look at what your fellow interns are doing that you aren't. are they taking all day and worrying about notes constantly? one thing i see in struggling interns is they want everything "perfect" in their notes and don't focus on why the person is there and what they are going to do to get them home. you are really only answering 2 questions. 1. why is this person in the hospital? 2. what do i need to do to get them home? if you can answer both those the little things fall into place. i think that is possibly the easiest way to see the big picture. hang in there. it'll click
 
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Dejavu

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take a step back and look at what your fellow interns are doing that you aren't. are they taking all day and worrying about notes constantly? one thing i see in struggling interns is they want everything "perfect" in their notes and don't focus on why the person is there and what they are going to do to get them home. you are really only answering 2 questions. 1. why is this person in the hospital? 2. what do i need to do to get them home? if you can answer both those the little things fall into place. i think that is possibly the easiest way to see the big picture. hang in there. it'll click

This. Powerplant1 must be a smart doctor.

Looking back on internship, I still feel these same things about myself as an intern. I sucked.
I spent four yrs in the Marine Corps, and I would rather do those 4 yrs again, than my internship year again.
But, I got through it, didn't kill anyone, and just retired, 25 yrs later, not having killed anyone.
When I teach in the OR, I try to get residents to break everything they can into a two choice algorithm, just like the above post, but only after answering the initial two questions above.
 
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JustPlainBill

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I feel your pain -- I did such an outstanding job on ward medicine my intern year that it was recommended that I take an elective month in ward medicine during pgy2 -- I did and did so well that I wound up on probation for it and had to really work hard to recover. What got me was that I was timid on wards -- not realizing that 1) it's pretty doggone hard to kill someone unless you really do something stupid -- like dose 10g of potassium IV push and there's usually a team monitoring the patient 24x7x365 -- yeah, you may get barked at for a screw up. I just didn't want to be the guy who shoved a patient over the edge. After getting beat up so badly in intern/pgy2 year, I just said screw it and did what I had to do to survive since anything I did was never good enough anyway --- rather than be an adult about it and really work hard to learn/understand enough, I just wanted to survive the rotation and graduate, knowing that there was no way on God's creation I was doing ward medicine in the real world.

Now -- you gotta get through this -- What's probably happened is you got so bogged down in the technical aspects of ward medicine -- perfect H&P, progress notes, etc. that you didn't learn the medicine part -- so, after you've done 10 or so admissions, you should have the basic plan down cold -- what are they here for, what are the to 5 things to rule out, how do I do that (labs, imaging, etc.) why do I think it is what I think it is (good HPI), what chronic conditions do I need to manage (look at the med list -- every medication should be tied to a condition that will make it into your A&P), what hospital specific stuff do I need to order (diet, DVT PPx, PT/OT, etc.) and how do I want to do my labs -- do I just want to put them on autopilot and get a CBC/CMP/whatever daily as appropriate or do I want to put in my labs at the end of the day, thinking about what I'll need tomorrow and what conditions I'm tracking (also depends on the philosophy of the attending/seniors) --

Once you get them admitted, then you take the time each night (sucky part) to read up on their conditions in a quick clinical resource (I like UpToDate and Pocket Medicine) -- make notes in your lab coat resource that you have on you all the time (right there with your FOBT developer, 4x4s, tape, scissors, hemostats, granola bar) on unusual things for any admissions --- rather than be overwhelmed with the entire census, know the big things on each patient -- i.e. anemia, copd/asthma exac, dka, cellulitis and what the treatment plan in general is --- but know yours very well -- For example: Ok, I've got a pancreatitis in an alcoholic, studies show not to trend amylase/lipase daily but get one QOD and track belly pain, hold them NPO until things start trending down, advance diet as tolerated, think about ETOH withdrawal and how much Librium and my scheduling of benzos, what should I expect to see and what did I see out of that patient (that is not what to do but you get the idea -- look up current treatment algorithm for this) -- you'll see it again and then see it as outpatient in clinical practice as an attending -- you'll draw on those resources since the way the patient reacts in the hospital will tell you what generally happens and WILL influence your clinical practice later. I can tell you I've had patients with increased SCr that I started to get concerned on until I recalled that on inpatient I had a psoas abscess that was treated with Vanc that smacked the kidneys and SCr went to 6 -- renal refused to dialyze because of no uremic symptoms -- kidneys recovered after a few days and SCr returned to slightly above WNL and eventually WNL -- taught me something I could use later on.....

Remember -- when you present, don't be nervous because you'll come across that way -- Have the mindset that you're communicating essential information to a more experienced colleague that you're asking for a second set of eyes on the case -- if you take that approach, you'll come across as more confident -- also, don't take any A&P changes as criticism, just as "Ah, ok, you're right, I never thought about that" ---

lastly, recognize that you CAN do this, you are a Physician -- not an NP, not a PA, not a chiropractor or podiatrist or whatever --- you're a physician and you've earned the right to be there -- it's truly about self learning and confidence ---

Remember to take some time for yourself....
 
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RadOncDoc21

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To all of those who claim they never killed anyone, how are you so sure you haven't? Are our actions justified? Usually the answer is "yes," but I can't claim that all of my actions haven't been without serious consequences.

I just remember my very first day of intern year, our attending had us look at our hands and repeat after him "these hands can kill!"
 

surgonc2017

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One of the nice things about surgery residency - you're sure you've killed someone.


Sent from my iPhone using SDN mobile
 
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