PGY1 needs help

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morethanhuman

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PGY1 who needs career help. I like internal medicine so far but am not good at it for various reasons. I have difficulty in such a fast-paced environment with lots of pressure, I mentally can not work at such a speed, and have a difficult time with multi-tasking and being pulled in all different directions multiple times a day. And with the added time limit on my day per the ACGME guidelines, I cannot get everything done that I would like on my patients. I wind up taking so much of my documentation work home which allows me less time for reading, learning, sleep, etc.

I have been thinking of switching to a pathology residency (I ultimately want to do research) but am not sure that is the right course of action. I really need to talk to someone about this because I feel intern year is taking a tremendous toll on my health and well-being. I am happy when I see patients but everyday I come home and want to cry due to the incredible stress. Also my knowledge of clinical medicine is subpar. I have tried to sit down and learn, learn, learn but I have memory issues and I cannot always remember the best way to treat diseases and can't for the life of me remember journal articles. At this point I know as much as 3rd year medical students I feel.

I'm wondering if I should speak to my PD about this. If I do, however, I feel like he may not want to keep me around and may decide to get rid of me. I know someone in the research field who I may want to work with someday. But if I speak with her she may get the idea that I can't handle things as she did and may not want anything to do with me later. And I don't know any objective physician that I can speak with about this.

I am really at my wits end at this point and need help. I would appreciate comments, particularly from IM PDs.

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I am a solo internist in private practice now for 11 years. Your statements that "I like internal medicine so far" and that "I am happy when I see patients" is enough for me to recommend that you hold on. Internship is and should be stressful. Good. Let it help you to grow into a better clinician. I take work home nightly also... and it is ok. Your feeling inadequate is good for your patients. You will miss less this way.

Listen, general internal medicine is not easy. And I will tell you that years out of medical school, it does not get that much easier. You will slowly get better and faster. General medicine is a wonderful specialty that will allow you to truly take care of your patients. It is a fun and a very rewarding specialty. In less than three years, you can control how fast you see patients and how many patients that you see each day.

I strongly recommend that you do not change to a pathology residency. Pathology is not what it was 20 years ago. The market is terribly over saturated, which has resulted in near slavery working conditions. You seem to like taking care of people. Unless you want to deliver babies or see children, you are right where you should be.

I would be happy to give you additional feedback if you so desire. Hang in there.
 
Thank you for your reply, DIce3. I should clarify that I like some patients. When I have worked in certain doctors offices (generally in more affluent areas, sad to say) I enjoy it. At large medical centers like for residency, a lot of the patients are incredibly draining and I don't enjoy it as much. Also my ability to address multiple problems in a short amount of time is poor and that is why I would think about subspecializing to focus on a smaller amount of things. But right now I'm not sure if I can make it to that point. And do I even want to (putting myself through more of the same busy environment)?
What I like is the thinking part of medicine and residency to me has been all about paperwork and very little learning. The biggest problem for me in residency and beyond (as you are saying it does not get easier) is the efficiency part of it. I am a more detail-oriented person and want to have all the facts straight before I think about what to do for a patient. My short-term memory is poor and I like to go through the whole thought process. I feel like I don't have time in the mornings. I preround gathering all the facts for patients and don't have time to synthesize it before rounds.
You are the second person to tell me that a tougher residency will make me a better clinician. I don't understand how being more stressed out will make things better for me. It's a fact that stress does not help in the learning process and I'm there to learn. The stressful environment on top of my poor memory and slower speed make things close to unbearable. And no one will call me out on it, but I can sense the residents/attendings frustrations over my abilities.
More feedback would be greatly appreciated, thanks.
 
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I trained in at a large urban university but now live and practice in a small to mid size town. In training, you need to learn to pick up the rare diseases and sharpen your skills. The training is impersonal and a bit caustic, if not malignant, where I trained. You do not walk out after three years as a full package. Far from it. Where I practice, I end up treating nearly everything. This means that I am looking things up and reading all day trying to figure out what to do next.

In training, you move by fast and never build any real relationships with patients. I can now verbal order half of my patients medications including the doses to the ER nurse or pharmacist. It takes a long time for this to happen. The real joy in practicing medicine is the long term relationships that you will form with your patients. You will spend countless hours attempting to save marriages, raise children, keep people employed, etc. When calling "Ms. Jones" slowly evolves from you calling her "Ms. Jones" to you addressing her by her first name and her yours, the real practice of medicine has started.

The best clinicians I have ever worked with were a bit slower. What is the hurry? You have another 40 years left to practice. The paperwork may turn electronic but will only increase. There will always be a few harsh clinicians around you in a training program. Enjoy every minute of it. Just realize this first year will feel like walking through fire--maybe now even an inferno. Ignore the nonsense and keep on walking. Walk, learn, grow into your shoes. Doctor, the journey will be well worth it.
 
When I read your posts a rush of deja vu hit me.
A little background- I was in an academic IM residency program and had to resign due to some very unfortunate circumstances, but the reason for this was due to depression/burn out.
I know this now that I am out of the field, but when I was going through this personal hell I kept saying to myself "what the hell is wrong with me?" "why can't I keep up?" "****, what was the patient here for again?"

Do these questions sound familiar?

I really do feel and relate to your pain. IM training is brutal. you don't feel like your learning a damn thing. your expected to fill out paperwork you have no idea for what reason. your getting pulled in 10 different directions. you need to come up with a plan of the last admission of the day and write a H&P that likely no one will read.

I know my medical knowledge was below average, which just compounded my anxiety/depression. Off days were spent reading step up to medicine to figure out basic management issues. Re-reading articles or snippets on uptodate cause they don't make sense to you and you think it's only you that has a problem.

It's hard I get it, it wasn't met to be easy. Docs are expected to be super human sometimes.

I'm telling you all this because I don't want you to make the same mistake I did. I literally burned out. emotinal exhaustion poster boy! I went from being a happy go lucky guy to 24/7 anxiety and always unsure of myself. Even when I was not in the hospital I was thinking how the hell am I gonna do on my next ICU or ward rotation as a resident. I can't keep up with my 7-8 patients and you wanna double my load and supervise interns.
always thinking **** I don't know how to manage that or this.

Residency does not get easier like an attending posted and post-residency life is no walk in the park, but your tolerance for pain improves.

Please if you can, arrange with your PD for some time off or swithch to an outpatient month until you feel like you can breath easier. I would advise you to develop relationships with some good residents who can be your support system. If you don't know something call them for advice and vice versa. It does help. Ask other interns how they are keeping up, you may be surpised to find out that they feel the same way. See if your resident can advise on how to organize your day. Write everything down! you can't be expected to remember everything, but try your best.

Really self-reflect if you want to continue with this. Burn-out really is no fun and the consequences are not worth it. Like my family says there are a million and one ways a person can earn a living. In medicine we work ourselves to the hilt and falsely believe our lives are not meaningful if we aren't ordering blood cultures, IV antibiotics, giving somebody some nebs or diruetics. It's not true.

Good luck to you and I hope you find some peace.
 
Thank you both for your replies. DIce3, I entered medicine for those relationships and you are right, there is no time to develop them. It's always go, go, go. DIce3 - your last paragraph really struck me hard. I really hope it helps me to go forward.

newdude2009 - It is really good to hear your thoughts as someone who has gone through similar problems. Your questions are exactly what I think of daily. I don't know if I can keep up. And even compared to other interns, I feel like I'm below the curve. Every day I wake up anxious, even on off days.

I think I like IM enough that I could stick with it but my main concern out in the real world is that I don't want to be so incompetent that I wind up killing people. And as a 2nd and 3rd year I will be the one in charge. What scares me is that 2nd year isn't really that far away.

I am doing exactly what you did. Reading Step-Up to Medicine and Up-to-Date because I don't think I learned the basics too well, let alone knowing details about new studies and management in NEJM and JAMA.

I also have a tough time with organizing the story for each patient in my head. I've always been bad with telling stories so it's nothing new. And in medicine there are multiple stories to tell, one on rounds where you go into detail and one during signouts where you keep it short and to the point for overnight/most important issues. I'm really not good at either and it makes things harder for me.

One of my residents did tell me to try to not read from the papers and present patients (at least the basics) from memory. Obviously I can look at the paper for labs, vitals, etc. I will try to speak with other interns about what they are doing. I have been on outpatient months already and yes, they are less stressful generally but have their own kind of stressors.

I think my problems stem from a subpar knowledge base, lack of confidence due to the lack of knowledge, and problems with memory and thought organization.

I have considered switching to either pathology or just research or maybe something out of medicine all together. I don't know. Like you said though, I need to find some mental peace and that is my ultimate goal in life. Thanks again for your input.

Can I ask what you wound up doing after resigning? What options are there if I do decide this is no longer for me?
 
A couple of thoughts:

1. I agree that depression/burn out can be an issue. We don't usually see it this early in the academic year, but it' still possible. If so, then your performance may be worsened by it and I would encourage you to be evaluated for it. As you already know, it's a subjective call. We don't have a Depression-O-Meter that tells us if you're depressed or not.

2. I would encourage you to speak with your PD now. There are really two possibilities: either your performance is fine and you've just set ridiculously high standards for yourself, or your performance is truly sub par. If the former, then perhaps hearing this from your PD would help. If the latter, your PD is already worried about your performance and you taking the initiative can only help.

3. It happens that people want to change fields. Path is not easier than IM, but it does draw on a different skill set and perhaps that would be a better fit for your skills. If you want to apply to path, you need to do so now. Match season is now, interviews will start shortly. You'll need to do a path rotation to get some experience (and to be certain that you really like it). You'll then need time for interviews. You'll need a letter from your PD. All of this requires that you get started now.
 
Thank you, aPD.
1. I don't think I'm depressed. Intern year is going cause some bit of sadness that I think I may have.
2. My evals are somewhat ok so far. Not stellar, not horrifically poor. So I'm not sure what my PD would have to tell me. I think I'd only talk to him if I really decide IM is not for me.
3. I realize path is not easier than IM. I was not implying that. I'm not afraid of hard work but would like to know that I am good at what I am doing and have potential to get better. Not everyone has abilities for every specialty.
 
I would agree with what aprogramdirector has said, but before you go to your PD you may want to ask upper level residents do they know what has happened to weaker interns in the past. If you go to your PD and explain your situation you might be putting a target behind your back, so be careful. Not all PD's are created equal. I was very fortunate to have an amazing PD who really was a strong resident advocate, but your PD may not be the same.
I should have mentioned this in my first post, but I tend to think all PD's are like the ones I have dealt with.

From what you are telling me it sounds like the pace of the hospital environment is not your cup of tea. correct me if I'm wrong.
If that is true I would also consider family medicine as well, which might be easier to transition to. The residency tends to be more outpatient focused in the R2 and R3 years, but you will also have to deal with some OB and peds rotations as well. Emergency medicine is another option as well, with shorter work weeks. You will most likely due a rotation in the ER during your intern year.

Setting up a path rotation may not be so easy as well for you since it would require a change in your schedule and your fellow interns, but it's worth a shot if your heart is set on it.

I'm lucky in that I have very supportive family, so right now I'm doing fine.
My sincere advice would be to really keep focused on your task at hand. Being a physician is really a very prestigious career and you will be in demand, but I do understand your predicament. I wrestle with my decision everyday. I hate to see you do something that you might regret.
You will have to make up your own mind in the end, but it is important to know that your not alone.
 
morethanhuman, i completely understand what you're going through. i was an intern last year and it's a year i don't like to think about.
the thing that makes it the worst year is that all of the tasks (scut and all) fall on you. you have consults to call, labs to f/u, make sure pt's get their tests done, f/u the consults, discharges with summaries, meetings, noon conferences, order labs for the following day, and then admit on top of it. additionally, where i was intern year, we had social work rounds right smack in the middle of the morning which was always a treat. and by treat i mean waste of time.

there is no way you can be proficient at all of this in Oct. and everyone knows it. hopefully u have supportive residents and attendings. unfortunately, i had the latter but not the former (most of the time). what can ya do?
it was not easy for any us. it's no wonder we feel like we have a deficit in our funds of knowledge. there's really no time to stop, look things up and absorb.

i was so burnt out by february i was investigating switching specialties. i really couldn't handle it any longer. i was actually very close to switching...
but i came to the conclusion that if i switched, i would later regret it. so here i am, sticking with it.

it certainly is better as an R2. residency still isn't fun. but it's bearable.
 
IM residency is not that fun, especially as an intern, but the IM job market is actually quite good and IM is a good springboard to specialties like endocrine or rheum or allergy/immuno (where you'd have more time to think about stuff and less scutwork to do). I think it would be premature to throw in the towel, although it's OK to go for path if that is what you want. Right now I am not hearing strong signs that you have a burning desire to be a pathologist...just that you are scared sh*tless.

I do think you should do some things before you get yourself into a potentially bad situation. First, remember that you may be overexaggerating your level of weakness...however, if you think others have noticed you being slow and maybe having poor verbal presentation skills, then it probably is really happening, at least to an extent.

I agree w/the attending IM doc...everyone in internal medicine feels overwhelmed by the paperwork and multitasking sometimes...or even often. It's one of the crappy things about our specialty. However, EVERY specialty has crappy things about it. ER has violent patients and family members, a physically tiring environment (traumas, etc.) and you have to deal with calling people to admit patients and do consults they don't necessarily want to do. Surgery has crappy hours and sometimes harsh personalities to deal with. OB/gyn and all other invasive specialties have stress from higher lawsuit risk. Pediatrics has crazy parents and veterinary-like patients. Pathology has...I don't know...a crappy job market and perhaps boredom and volumes of literature to read, pictures to memorize, etc. I'm not sure you've given me enough reason to think you should bail from internal med at this point.

Some things that may help you:
-don't think you have to know "what to do" in every situation. The good thing about being an intern is you can collect the data (labs, history, etc.) and try to propose what to do but you DON'T have to be right all the time and you can punt to a higher level like the resident or attending at this point in the year - particularly if the patient is pretty acutely sick. DO get information and assess a patient before calling for help, unless he's REALLY crashing. That means get the vitals, get the ECG, eyeball the patient, etc. Then you have done your part.
-I see interns spending too long on discharge summaries and writing too much. What people really want is day of admit/day of discharge, the MAJOR hospital events in brief, and what discharge meds the patient was sent home on, and a clear followup plan (like a f/u clinic appointment, labs next week, etc.)
-Don't bother with trying to read a bunch of journal articles. For work, you can use something like Pocket Medicine to give you brief workups for common medical conditions, and then look up Uptodate briefly while you're doing a new H and P or if your patient turns out to have some new problem
-Try practicing at least the first few lines of your oral presentations in front of a mirror at night. I know it looks funny but it may help. People listen to the chief complaint and first couple sentences, and then they zone out, so make sure that part is good.
-Your daily notes - don't cut and paste stuff that is JUST WRONG (if you're using EMR/electronic records). DO briefly give short, up to date overnight events, physical exam, and assessment and plan of active problems and briefly describe what you're going to do.
-A lot of the interns I think who were better than me actually had some short of cheat sheet they used on rounds...one had a white piece of paper with template for labs, imaging, etc. that he would write on for each patient every morning, and carried around a little clipboard. It worked for him and nobody could say he didn't have his patient's labs, etc.
-Remember you have to eat and sleep. Otherwise you just become more stupid and slow...it's like a vicious cycle. I suggest stashing some water and powerbars somewhere, like in your car or a resident work room.
 
Oh year, I also would not recommend talking to your PD or chief resident at this point, unless you are really sure they can be trusted.
Perhaps one of the upper level residents who seems to be helpful. Try to see whether they can give you specific tips on succeeding in the program.

Also, if you feel like you are struggling on a rotation, if the senior resident seems reasonable, it may help to get him/her in your corner by admitting that you think you're having trouble with all the speed and multitasking. If you bring it up this way then it's kind of harder for them to trash you or get frustrated with you...this way you put the ball in that person's court. Perhaps he/she becomes invested in you succeeding, to some extent. An attending suggested this to me at one point during residency, and though I don't think it works on some people (ones who are just selfish or have not much patience) it probably works on most people unless you are obviously not pulling your weight or doing ridiculous stuff.
 
Also, remember that 1/2 of interns are a "below average" intern at any given point in time.
 
Thanks to all of you who posted. Life has been very busy and so I had no time to post earlier.

I understand what you all have said and it makes sense. It helps to get objective assessment of my thoughts. I suppose what I'm looking for ultimately is a slower-paced practice where I can think more and not just do all the time. I chose IM because of the thinking and turned against surgery because it was too much doing and little thinking (in my opinion). I do believe I still enjoy working with patients. I suppose I mentioned pathology because I thought it was slower-paced and I think it may fit in better with my abilities (I'm a visual learner). That is what makes IM harder. On rounds when people are saying this, that, and the other, I need to visualize it and think about it but sometimes there is no time and it's harder for things to register.

newdude - I don't think I would switch to FM. Although it might be more outpatient, I'd rather focus on 1 population (adults) instead of having my mind go all over with med, peds, ob/gyn.

revolution1980 - thanks for sharing your experience. i wouldn't say i'm burned out right now. i definitely do take time out for myself. just feeling overwhelmed by the amount of work that i'm responsible for combined with the fact that i don't think i'm doing a great job with it - this produces anxiety which makes things worse. i think i will stick with it for now. the thing that helps the most is just thinking that december is not too far off and that means halfway done with intern year.

dragonfly - thanks for all your thoughts and suggestions. i hope they will work and make things better for me.

i think i will stick with IM right now. thanks again for helping me through this difficult time, everyone.
 
Thanks to all of you who posted. Life has been very busy and so I had no time to post earlier.

I understand what you all have said and it makes sense. It helps to get objective assessment of my thoughts. I suppose what I'm looking for ultimately is a slower-paced practice where I can think more and not just do all the time. I chose IM because of the thinking and turned against surgery because it was too much doing and little thinking (in my opinion). I do believe I still enjoy working with patients. I suppose I mentioned pathology because I thought it was slower-paced and I think it may fit in better with my abilities (I'm a visual learner). That is what makes IM harder. On rounds when people are saying this, that, and the other, I need to visualize it and think about it but sometimes there is no time and it's harder for things to register.

Yeah...that's just life as an intern. One way or another, you will get through it.

Intern year is about 98% doing and 2% thinking (usually after the fact, wondering WTF just happened and how you managed to not kill the patient). Things will shift over the next couple of years and you will spend more time thinking and less doing (that's what interns are for after all).

Everybody goes through this same thought process at some point...the ones who say they don't are lying to themselves (which is OK...it's a valid coping mechanism).
 
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