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....
