pre-internship anxiety

[IMdocT]

Hi, I've lurked in this forum throughout med school, and it has been useful. So now I have a problem to pose to peers and seniors. It's 1 month until my IM categorical residency, and this weekend I just started to panic to the point that I'm physically feeling like crap. I've been justifiably anxious about stuff before but it never made me feel like this. I haven't been very studious in med school and it's reflected in my exam scores (shelf and Steps). I basically did the minimum to pass. At one point in med school I was thinking of changing career paths but decided to hang on and at least complete the MD, and now I'm off to a 3-year residency. My last medicine rotation was 8+ months ago and I feel like I've forgotten so much and that my knowledge base is weak to begin with. The things that keep going through my mind are that I'm not ready, being afraid of mistakes/disappointing people/harming patients, whether I chose the right career.

So I have 2 questions; first is has anyone felt this way too and what did you do? I feel like it won't go away until I start internship and it hopefully turns out to be not as bad as I imagined (but then what if it were as bad or worse?).

Second is I really think I do need to do some reading, so if anyone was in the same boat, what materials might help? I did see some recommendations here http://forums.studentdoctor.net/showthread.php?t=715458.

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[peppy]

I think this is a common worry. The good news is that everyone looks really stupid in July. Most of what you learn in med school isn't really that relevant to what is actually practical to functioning in the hospital where you're going. You'll catch on. Don't be afraid to ask questions. They expect it in July.

 

[Ash MD]

I have pre-fellowship anxiety. We r normal. Go Work out at the gym like crazy!

 

[IMtoHO]

Impostor syndrome is going to kick in in a few months!

 

[IMdocT]

Thanks for the replies. I think internship will not be as bad as I feared. I'm feeling better today; I hope I can shake it all off soon. I wonder if it's like an actual depression or post-grad blues. Wonder if I can prescribe myself Prozac with that fancy temporary license >.<

 

[Ariee]

umm, yes I feel the exact same way- thank G, i'm not the only one...

 

[gutonc]

If you're not scared, you're not paying attention. And I'm scared of you.

A little fear is healthy...it will keep you on your toes. When the fear goes, you should go.

 

[PartyPants]

Hey there,

Your anxiety is normal. Starting internship is like standing on the edge of a really, really high diving board after spending 4 years of med school just cannon-balling into the shallow end. Once you take the plunge, it's not as bad as you may have feared.

Remember that you do have senior residents as back up, and more often than not there are experienced nurses near by who will hesitate to execute wild orders that don't make sense. Nurses, residents, and attendings tend to be a bit more vigilant in July than they would be in June; so be reassured that you won't be alone in all of your decision-making. Also remember that call days/nights may be fast-paced, but you do have 5 minutes to sit down in front of a computer and look up basic management in Up to Date or in whatever pocket manual of medicine you carry. The first month of internship isn't about pulling up the latest articles about COPD; that can come later once you've gotten down a system of being organized and have become more efficient. If you do suspect that your fund of knowledge is truly lacking and that you're not just having the usual pre-internship jitters, reviewing Up to Date articles or basic Pocket Medicine sections on common problems like CHF, COPD, community-acquired and health-care associated PNA, GI bleed, and chest pain will be a good starting place; and of course you should do your reading by the pool.

And finally, if you feel pressure from being at the bottom of the totem pole, remember that the only people you really need to impress are your patients. If you pay attention to details, work efficiently and courteously, and advocate for your patients, everything else will fall into place.

Good luck!

 

[C Chance]

Hey there,

Your anxiety is normal. Starting internship is like standing on the edge of a really, really high diving board after spending 4 years of med school just cannon-balling into the shallow end. Once you take the plunge, it's not as bad as you may have feared.

Remember that you do have senior residents as back up, and more often than not there are experienced nurses near by who will hesitate to execute wild orders that don't make sense. Nurses, residents, and attendings tend to be a bit more vigilant in July than they would be in June; so be reassured that you won't be alone in all of your decision-making. Also remember that call days/nights may be fast-paced, but you do have 5 minutes to sit down in front of a computer and look up basic management in Up to Date or in whatever pocket manual of medicine you carry. The first month of internship isn't about pulling up the latest articles about COPD; that can come later once you've gotten down a system of being organized and have become more efficient. If you do suspect that your fund of knowledge is truly lacking and that you're not just having the usual pre-internship jitters, reviewing Up to Date articles or basic Pocket Medicine sections on common problems like CHF, COPD, community-acquired and health-care associated PNA, GI bleed, and chest pain will be a good starting place; and of course you should do your reading by the pool.

And finally, if you feel pressure from being at the bottom of the totem pole, remember that the only people you really need to impress are your patients. If you pay attention to details, work efficiently and courteously, and advocate for your patients, everything else will fall into place.

Good luck!

I too am scared out of my mind, kind of coasted through med school. Any tips on how to be efficient? It took me forever to round on just 3-4 patients as a student (maybe 2 hours) - how am I going to pull it off on 10 or more if I plan on arriving on site at 5:30 - 5:40 am to preround. As for A/P, is it enough to just come up with what we think is best and then run it by seniors or attendings? My school unfortunately never went over how to come up with A/P and I just kind of made it up as I went along.

 

[IMdocT]

thanks again for the replies. i have the questions posed above, too.

for organization/efficienty, i think it comes with practice. i heard that some ppl have used things from binders full of H&P's to index cards, to PDA/phone apps. i searched the IM forum section and found 2 relevant threads
http://forums.studentdoctor.net/showthread.php?t=677011
http://forums.studentdoctor.net/showthread.php?t=714407

in med school i could print from the EMR a rounding report with recent vitals/labs, problem list, and current meds. it saved so much time. then i would jot down details for my progress notes and make a to-do list on it during prerounds/rounds. it was pretty good but used lots of paper just for a 2-4 patient load. i'm sure this can be further improved. i'm going to be on the lookout to try new methods that might help me more.

as for a/p, i think that comes with experience too. but i also wonder how much seniors/attendings expect from interns about a/p. it was so variable in my rotations. in some places the student did all the data gathering and stopped before a/p, while others expected a little to a lot of input. i think that's a big part of my anxiety; being afraid that my differentials and a/p aren't up to par with expectations, looking incompetent etc, given my inconsistent past experience.

 

[PartyPants]

Hey guys,

Those are great questions.

In terms of efficiency, that will come with practice. Rounding cards/sheets are good, but they don't have to be your priority in the morning if you're struggling to see patients and get a plan down. You should ask your resident and attending at the beginning of the month what their expectations are, like if they expect your notes to be finished and in the chart before rounds or if you are able to fill in some of your notes during rounds as long as you have a plan formulated in your head. Establishing expectations upfront will help prevent you from getting smacked in the face with negative feedback at the end of the month and allow you to have a concrete framework from which to work and to improve. Also don't forget to solicit feedback at the end of your first week to check in and see how you're doing and if your resident has any suggestions for how you can improve.

As an intern, yes, you do need to come up with an assessment and plan. You are no longer just presenting information, which is a good thing because being a doctor requires clinical reasoning, not just data collection. You will be coming up with a problem list with each admission and thinking about management, and the problem list tends to carry over for each day of pre-rounding (and will change throughout the hospitalization if the patient experiences acute events during the hospital course). Asking your resident to run the list and key elements of plan each morning before rounds will be helpful during your first few wards months; that way you'll be on the same page, and you can be backed up by him/her during rounds if there are subtleties to the plan that you didn't quite understand. Again, coming up with the assessment and plan will be key, but you have resources like Up to Date and Pocket Medicine that can help guide you on basic management for diagnostic tests and therapies. For example, a COPD exacerbation at the VA may have a problem list like this:
1. COPD exacerbation / hypoxia: (then fill in your asessment of how the patient is doing for this problem, etiology of exacerbation, and how you are treating the patient)
2. CAD: s/p MI in 2009 with BMS to LAD .... (then fill in your plan on how to manage this)
3. Microcytic anemia ...
4. T2 DM ...
5. GERD ...
6. Microcytic anemia ...
7. Depression / chronic pain ...
8. FEN
9. Prophylaxis
10. COR status
11. Dispo:

Your resident will help you with this and talk to you about why prednisone vs. IV steroids, or why he or she decided to do nebs rather than MDI (and then the next day the attending may talk about a CHEST paper that demonstrated no benefit in using nebs over MDIs), and that is part of the learning process. Remember, you have back up as an intern, and there will be more hand-holding in the beginning. 6 months into intern year, you will feel more sure of yourself and feel like you're able to fly solo for the most part. By the end of intern year, you'll feel annoyed that you're still being managed by a resident.

Hope some of this helps.

 

[DO it right]

talk about stress....i'm starting with a month in ICU

 

[C Chance]

Hey guys,

Those are great questions.

In terms of efficiency, that will come with practice. Rounding cards/sheets are good, but they don't have to be your priority in the morning if you're struggling to see patients and get a plan down. You should ask your resident and attending at the beginning of the month what their expectations are, like if they expect your notes to be finished and in the chart before rounds or if you are able to fill in some of your notes during rounds as long as you have a plan formulated in your head. Establishing expectations upfront will help prevent you from getting smacked in the face with negative feedback at the end of the month and allow you to have a concrete framework from which to work and to improve. Also don't forget to solicit feedback at the end of your first week to check in and see how you're doing and if your resident has any suggestions for how you can improve.

As an intern, yes, you do need to come up with an assessment and plan. You are no longer just presenting information, which is a good thing because being a doctor requires clinical reasoning, not just data collection. You will be coming up with a problem list with each admission and thinking about management, and the problem list tends to carry over for each day of pre-rounding (and will change throughout the hospitalization if the patient experiences acute events during the hospital course). Asking your resident to run the list and key elements of plan each morning before rounds will be helpful during your first few wards months; that way you'll be on the same page, and you can be backed up by him/her during rounds if there are subtleties to the plan that you didn't quite understand. Again, coming up with the assessment and plan will be key, but you have resources like Up to Date and Pocket Medicine that can help guide you on basic management for diagnostic tests and therapies. For example, a COPD exacerbation at the VA may have a problem list like this:
1. COPD exacerbation / hypoxia: (then fill in your asessment of how the patient is doing for this problem, etiology of exacerbation, and how you are treating the patient)
2. CAD: s/p MI in 2009 with BMS to LAD .... (then fill in your plan on how to manage this)
3. Microcytic anemia ...
4. T2 DM ...
5. GERD ...
6. Microcytic anemia ...
7. Depression / chronic pain ...
8. FEN
9. Prophylaxis
10. COR status
11. Dispo:

Your resident will help you with this and talk to you about why prednisone vs. IV steroids, or why he or she decided to do nebs rather than MDI (and then the next day the attending may talk about a CHEST paper that demonstrated no benefit in using nebs over MDIs), and that is part of the learning process. Remember, you have back up as an intern, and there will be more hand-holding in the beginning. 6 months into intern year, you will feel more sure of yourself and feel like you're able to fly solo for the most part. By the end of intern year, you'll feel annoyed that you're still being managed by a resident.

Hope some of this helps.

First, thanks for your replies. Another question I have is that I always hear interns have little to no time to read SO does the knowledge base essentially stay the same as the day we left school? Or does "learning by doing" acutally work? Personally I always found that mantra a little suspect. For A/P my plan is to cobble together some plan (no matter how half-assed it probably will sound) and hope I have kind seniors to tell me "no you idiot, try this" but in a brotherly/sisterly kind of way.

 

[PartyPants]

DO it right: Starting out in the ICU sounds stressful, but you can do it! You will have resident and fellow backup, and you will learn how to cross-cover on sick patients quickly (and your resident should help you out too if you're struggling with the cross-cover). The most important rule of working in the ICU as an intern is: never hesitate to ask questions. If you're unsure about something, ask. Also, make friends with the ICU nurses, because they are usually fantastic, knowledgeble, and accustomed to gently guiding housestaff in the right direction. I'd pick up a copy of the ICU book (I think it's by Marino, and it's dark blue with white lettering) to read during your month - it's a quick and easy read, appropriate for an intern. Of course, there is a thread debating which resource is the best, but I'd say that if you're just trying to get through the month, the Marino book is completely fine (and you could get through it in less than a week). Getting familiar with early goal-directed therapy in sepsis and how different types of shock present would be a good starting point for topic review your first few days there. If you have never rotated through the ICU before, there will be other things that books cannot prepare you for: family meetings about end-of-life care, a real code, and all the alarms/beeps that are constantly going off. I'm not trying to freak you out, but it's good to know that your experience will be quite rich (and I would say rewarding). In August, you'll be well prepared for wards or whatever rotation you're doing. For now, just relax and have a rudimentary plan for how you would approach the month once you get there.

C Chance: It's true that interns don't get a ton of time to read, but it's okay! You will learn a lot, but it won't be in the format you're used to (from text), and you may not notice it until a few months into the year. For example, the first time you admit a patient with end-stage liver disease 2/2 EtOH hepatitis, you'll probably quickly skim Up to Date or Dynamed for basic info and management. On your post-post call day or pre-call day, if your service isn't insanely busy, you might look up a review article about it and read more in depth. A couple of call cycles later, you'll probably admit another ESLD 2/2 EtOH hepatitis patient, and you'll have to refresh your memory about it on Up to Date again and again note that steroids are recommended. Then you'll recall that the review articles touches on how controversial steroids are and see a reference to a study about it - you look up the reference and print it for some other time. The third time you admit ESLD 2/2 EtOH, you'll probably remember what you're supposed to do because you remember your first 2 ESLD patients and wrote their orders, and then you finally get a chance to sit down and read the study and assess its validity. Learning happens in fragments - you can't read the latest articles about every problem on the problem list for all your patients, but most attendings will make references to the most important articles to skim (and you could probably just skim the abstract - no need to do formal critical appraisals unless you're going against the grain and trying something radical studied in a small RCT). Your fund of knowledge will grow in clinically relevant areas, and you will learn a skill set that books can't teach. You might forget the details of the coagulation cascade that you learned for Step 1, but you won't forget to check an INR in your ESLD patient. I hope that makes sense.

 

[jdh71]

I had a whole year off doing basic science research prior to starting internship, and it went ok. You'll be surprised I think by what you still know. Don't get me wrong it will be a bit of nightmare for the first few months, but that's the way it iis for everyone.

You will always have backup. As an intern the first few months your job is not to think much at all, but to simply do as you are told. I would suggest paying attention during this time, because as a PGY-3 come September/October, I'm going to start expecting more . . . for instance IV fluids . . . if you're still asking me on a basic patient you were not paying enough attention, and by January I shouldn't have to do much except make sure the team flows. So in your first few months if you don't know ASK!! No one will hold it against you, I asked all the time about everything when I showed up, BUT I paid attention, so I rarely ever had to ask again. In fact, if I find out you didn't ask when you didn't know, I will breath fire up your ass. Ultimately, I can only be as good a supervisor and teacher as you allow me to be, so use my experience.

Never lie. Never, ever, make up any data. NEVER say, "I think it was X" when you have no ****ing clue whatsoever. If you do this and I find out, I'll never trust you again, and I will breath fire up your ass. "I can't tell you that information" has been one of the most valuable senetences for me during my internship. Did I occasionally meet the ire of an attending, fellow, or senior resident? Sure, but you know what? They knew they could trust me. Just don't miss the information again in a similar situation and no one will even remember the incident but you. "My mistake. That will not happen again." was a close second in value to me. You WILL make mistakes, own them, NEVER do them again.

On IM you really seem to admit like 10 diagnosises (is that the proper plural?) regularly, for the most part. It would behoove you to make sure by the end of your first few months that you know how to write the basic admitting orders for any of these frequent admitting problems. By September if I have to tell you the initial management and admitting order for your basic COPD exacerbation, I might yell at you (nicely, as in hey, man, you really should know this by now). Even though some of the pocket books have this information, I kept a separate pocket note pad on which I wrote admitting diagnosis and admitting orders (with variations that were attending specific when appropriate).

Do not fight about consults or admits when called. My job as senior (and the same can be said for the fellows on your sub-specialty rotation) is to protect you and the team from bull****. Let me know you were called, if we're going to fight it, let me do it. There is no reason to get bent out of shape fighting a consult, because I promise as an intern, you'll get mad and try and block for a few hours and then end up doing it anyway, going home late.

Organization . . . some people keep binders. Some people keep a copy of the daily notes for every patient they are following in their pocket. I did not do either, which occasionally got me into some hot water when I didn't remember the magnesium from four days ago, but for me, it was an exercise in training myself to remember what was important without the "crutch" and it has more or less worked. I get to learn what is important information by the withering looks I get when I don't remember and from then on out I do. I would recommend trying the binder method to start with and evolving your organization from there. Throwing everything into a clipboard, sound good on paper, but I think it's a bad idea because you could bump into the wrong person and then it's all everywhere. Clipboards were good for students, not so much for resident, IMHO.

Finally, be social. Which can be tough. For the first month I often only wanted to come home as sleep by 8 . . . but these people are the guys you will be doing this with for the next three years. Organize a liver rounds after work. Going through it together will make it seem much less lonely.

You guys will be fine, I'm sure. If a sorry, poor excuse for like myself can be brought up to snuff, I'm very confident that the rest of you can too.

I found posting SDN helped. FWIW . . .

 

[gutonc]

You WILL make mistakes, own them, NEVER do them again.

jdh71 said a lot of great stuff up there. This point however is, far and away, the most important thing he said. You will screw up, it's part of the learning process. But the best way to turn a learning experience into a disciplinary experience is to not own up to and learn from them.

Getting yelled at for a mistake by your senior or attending (which, unfortunately, will happen) sucks. Getting fired from your residency (either for lying or for pattern of behavior showing you don't learn from your mistakes and continue to endanger patients) sucks a lot more.

 

[PartyPants]

In a strangely poetic way, you can totally tell from these posts who is an intern, a senior resident, and a fellow. Notice how I've been writing very long paragraphs, jdh71 wrote a great and thorough response but in fewer words and posts than I did, and gutonc as a fellow wrote the least. They definitely have some great advice, and as they are speaking from a supervisor standpoint, you should definitely take note of their pearls of wisdom.

Nothing will get rid of the first-day jitters, so be reassured that being nervous is normal. Gosh, I still remember my first week of intern year as if it were yesterday. I started out on a CCU month and was terrified, especially since my first day was a call day. The patients survived, and sure, there was some yelling that first week, but I survived as well.

The only other thing I'll add is to remember your place on the totem pole. Each program is a bit different in terms of the role of the intern, so unless your program explicitly says that you as the intern run the show and make the decisions despite what an attending says (and there is at least one program like this), don't forget to be courteous and diplomatic on rounds, even if you disagree with what your superiors say. This may sound simple and obvious, but when fatigue wears on you, diplomacy is the first thing that goes out the window.

Enjoy this next month; I wish I could rewind in time and be in that beautiful period between med school and internship again!

 

[jdh71]

Also, and this is VERY important . . . we do not talk about the call. In much the same way you don't bring up the fact that a guy is pitching a no-hitter, we do NOT TALK ABOUT THE LACK OF PATIENTS BEING ADMITTED!!!!!!

Never say the words "slow" or "quiet". If you do, I won't need to yell at you, you will deserve the fate that will come next.

Silly superstition? Ok, temp the fates, let me know how it goes.

 

[radiodoc99]

Keep some good resources with you for reference like UptoDate and websites like SDN for reference of difficult cases. Ask senior residents for a common calls guide and a lot of times nurses are helpful as well. You can always look up difficult concepts in books or using the Internet.

 

[jdh71]

One more thing to remember that just came to me. Remember this as well: really sick patients . . . they die. If you remember that you will keep many things in context, especially working in the ICU - it wasn't your decisions that harmed them, but the fact that they died despite everything you tried.

 

[Speculatrix]

binders? how big are these binders? they seem so unruly...

I was thinking of moleskines - any comments? Could dedicate a few pages to every admission. How to organize the blank space in them for each patient??

 

[Instatewaiter]

binders? how big are these binders? they seem so unruly...

I was thinking of moleskines - any comments? Could dedicate a few pages to every admission. How to organize the blank space in them for each patient??

I tried that during my acting internship. The problem I ran into was that some people stick around for weeks and you keep getting new patients. Before long you have patients strewn throughout different parts of the moleskin. So, you keep losing track of the pages different patients are on. Pretty soon you have a few one patient randomly in the front of the book, one patient randomly in the middle of the book and then a bunch in the front with multiple pages between all of them. It is just a complete hastle.

I liked sheets organized in a binder that you find on medfools.

 

[drfunktacular]

Many great bits of advice above...

My humble addition would be to keep in mind that although many of your co-interns who may have different backgrounds than you may seem more confident/capable than you feel you are, and this can cause some anxiety as well. However, confidence is not always justified by actual capability and some people find this out the hard way over the course of their internship. Just do your best, learn where and from whom you can (attendings, residents, co-interns... even students teach us things regularly), and try to have fun on a semi-regular basis and you will do fine.

 

[jdh71]

 

[OCallag]

Since it's getting a bump, I've got a stupid question:

Having done this for a week now and still having no f'ing clue what I'm doing >90% time, when does an intern start to feel confident about his decisions? I get a little nervous writing Tylenol orders at this stage in the game.

 

[jdh71]

Since it's getting a bump, I've got a stupid question:

Having done this for a week now and still having no f'ing clue what I'm doing >90% time, when does an intern start to feel confident about his decisions? I get a little nervous writing Tylenol orders at this stage in the game.

Probably varies by person. I started feeling a lot more confident about a lot of things by October, and probably by March I felt like I knew what I was doing in general most of the time.

 

[jdh71]

bumping

it is time

 

[francois]

oh great..now, im scared..

 

[survivordo]

You'll be fine, there are generally quite a few safe guards in place so you don't really F up. Don't be arrogant, if you start getting out of your comfort zone ASK FOR HELP there is always someone there to back you up, even if it is just another intern to run something past.

When do you start feeling comfortable? Varies for everyone but I would say most of us were doing well by Christmas but there is still at least one thing everyday that gives me a "hmmmmm". That's what makes it fun!

Survivor DO