Pressures in residency

[doc.Junior]

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Looking forward to the day I match and can stop thinking about "the next test" and my academic record. Just wondering, does it get easier in residency? I realize that PGY1 is often long hours, but unless one's trying for additional competitive fellowships (maybe they're all competitive?) presumably you can relax a little bit (of course, still being responsible and diligent) because there's less pressure to be padding your resume and self-presenting at the next step down the line.

Does that sound about right? Any other additional "next things" that residents have to be concerned about?

 

[thumbz]

At the end you'll take your boards - that test pressure is similar to taking the USMLE - but otherwise no, the test pressure goes away and it's lovely.

What no one tells you is the pressure of being primarily responsible for someone's life is so much greater. I would much rather be back in anatomy then having a patient circle the drain in front of me while I have no idea what to do.

Easier is all relative unfortunately.

 

[VA Hopeful Dr]

If you do OK in residency and are in a halfway decent program, ITEs and boards should be much less stressful than the Step exams.

Agree with above, its a whole new kind of stress though but this one seemed to me like a much more relevant level of stress. Sick patients getting worse should stress you out especially at first. That way when you're out on your own it'll be old hat to you.

 

[doc.Junior]

Thanks, you both. It's encouraging to hear from people who made it to "the other side" 🙂

 

[Dral]

It gets more difficult as you go on. In fact, at one of our national meetings recently, it was stated that things actually get more difficult as you go through your career as an attending. I'd say there is certainly some truth to that.

However, if you are talking about testing, I do every now and then think to myself how nice it is to not have to study for exams anymore. For my specialties, our MOC consists of doing 13 online questions three times per year. It's not something you have to study for - it's actually a bit enjoyable to do.

 

[doc.Junior]

It gets more difficult as you go on. In fact, at one of our national meetings recently, it was stated that things actually get more difficult as you go through your career as an attending. I'd say there is certainly some truth to that.

However, if you are talking about testing, I do every now and then think to myself how nice it is to not have to study for exams anymore. For my specialties, our MOC consists of doing 13 online questions three times per year. It's not something you have to study for - it's actually a bit enjoyable to do.

Would love to hear more about why it's perceived as more difficult, if you're up for sharing! I assume it's related to what @VA Hopeful Dr said about as resident, patients are relying on you, but that you're supervising those residents. Do you think some of the "harder" applies to people who aren't attending?

 

[VA Hopeful Dr]

It gets more difficult as you go on. In fact, at one of our national meetings recently, it was stated that things actually get more difficult as you go through your career as an attending. I'd say there is certainly some truth to that.

However, if you are talking about testing, I do every now and then think to myself how nice it is to not have to study for exams anymore. For my specialties, our MOC consists of doing 13 online questions three times per year. It's not something you have to study for - it's actually a bit enjoyable to do.

I'm curious on this because I absolutely think it gets easier on the whole as time goes on.

 

[doc_J61]

Make sure that you're in a specialty that you enjoy. If you're doing something that you enjoy, then everything will seem less stressful.

Having supportive family members and friends can help a lot, too. Like coping skills and hobbies, you have to make time for these aspects of your life, just like study time (albeit less so in med school and residency of course). Try not to look so far down the line and focus on the here and now. I know that it's trite, but if you value being in the present, you might not worry so much about the future.

 

[Dral]

To answer both of you, it could very well be the specialties I practice. Keeping up with the new knowledge is difficult. Also, the longer I practice, the more interesting cases with odd presentations I encounter. This makes decision making more difficult. If I come across a case that I perceive could be something difficult or something I'm missing, I put a lot more thought into what more I need to do to work things up. Early in my career I would just determine it's likely what I'm initially perceiving it is. As I learn and experience more, I say to myself "Hmm, it's almost certainly this, but what if it is this or a different presentation of that?" Setting the line to not overutilize medical resources has become something that has become more difficult for example. Basically I'm continuing to figure out that I'm 'knowing what I don't know'.

The part about everyone relying on you I don't think is something that stresses me out too much. However, I will also say that I have gotten more autonomy as my career has moved along and with that comes more responsibility to those who depend on you. So there is that as well.

I'll be honest, some parts are easier, some parts are more difficult. I feel it has gotten overall a bit more difficult, but not by much. I'd say in general, I'm happier with what I do compared to what I was doing in medical school though; and as I said, I do periodically stop and think about how much nicer it is to not have to study/cram for exams anymore.

 

[VA Hopeful Dr]

To answer both of you, it could very well be the specialties I practice. Keeping up with the new knowledge is difficult. Also, the longer I practice, the more interesting cases with odd presentations I encounter. This makes decision making more difficult. If I come across a case that I perceive could be something difficult or something I'm missing, I put a lot more thought into what more I need to do to work things up. Early in my career I would just determine it's likely what I'm initially perceiving it is. As I learn and experience more, I say to myself "Hmm, it's almost certainly this, but what if it is this or a different presentation of that?" Setting the line to not overutilize medical resources has become something that has become more difficult for example. Basically I'm continuing to figure out that I'm 'knowing what I don't know'.

The part about everyone relying on you I don't think is something that stresses me out too much. However, I will also say that I have gotten more autonomy as my career has moved along and with that comes more responsibility to those who depend on you. So there is that as well.

I'll be honest, some parts are easier, some parts are more difficult. I feel it has gotten overall a bit more difficult, but not by much. I'd say in general, I'm happier with what I do compared to what I was doing in medical school though; and as I said, I do periodically stop and think about how much nicer it is to not have to study/cram for exams anymore.

The first paragraph was going to be my best guess. Its one of the advantages of not being a specialist, I'm not the final word on anything. Weird rash that doesn't respond to anything I try? Derm! And if the targeted ads I see are any indication, y'all must be getting a new biologic for psoriasis every 3-6 months.

 

[eyeeye_captain]

To answer both of you, it could very well be the specialties I practice. Keeping up with the new knowledge is difficult. Also, the longer I practice, the more interesting cases with odd presentations I encounter. This makes decision making more difficult. If I come across a case that I perceive could be something difficult or something I'm missing, I put a lot more thought into what more I need to do to work things up. Early in my career I would just determine it's likely what I'm initially perceiving it is. As I learn and experience more, I say to myself "Hmm, it's almost certainly this, but what if it is this or a different presentation of that?" Setting the line to not overutilize medical resources has become something that has become more difficult for example. Basically I'm continuing to figure out that I'm 'knowing what I don't know'.

The part about everyone relying on you I don't think is something that stresses me out too much. However, I will also say that I have gotten more autonomy as my career has moved along and with that comes more responsibility to those who depend on you. So there is that as well.

I'll be honest, some parts are easier, some parts are more difficult. I feel it has gotten overall a bit more difficult, but not by much. I'd say in general, I'm happier with what I do compared to what I was doing in medical school though; and as I said, I do periodically stop and think about how much nicer it is to not have to study/cram for exams anymore.

It’s all of this, plus if you’re in any way surgical/procedural, you’re going to carry the ghosts of complications. That adds up over the years.

I was commiserating with my interventional cardiology neighbor last week about tough cases we both had that day that were probably going to keep us up at night.

 

[RangerBob]

The stresses are different. Instead of now worrying about will I meet expectations, pass my exams, and be able to finish the expensive and extensive route I started, now I worry about will I have the right answers, keep my patients alive (the buck stops with me now), and be able to keep supporting my family.

The stresses are different, but so intertwined with the aging process/having a family, that's it's hard to separate out what's more stressful.

Other than to say M3 was by far the most stressful for me due to the ever constantly changing rotation schedule. I prefer predictability/stability/autonomy, so that was the roughest year for me.

I can say with confidence is the things that stressed me out in residency rarely affect me now. Similar to now I don't worry about the stressful things from high school (will the girl like me back, how can I run 1 second faster in the 400m, did I remember to do my homework?, etc).

 

[doc.Junior]

The first paragraph was going to be my best guess. Its one of the advantages of not being a specialist, I'm not the final word on anything. Weird rash that doesn't respond to anything I try? Derm! And if the targeted ads I see are any indication, y'all must be getting a new biologic for psoriasis every 3-6 months.

This is pretty insightful. Usually it seems people think more specialization = better, and I haven't heard this angle expressed before.

 

[doc.Junior]

It’s all of this, plus if you’re in any way surgical/procedural, you’re going to carry the ghosts of complications. That adds up over the years.

I was commiserating with my interventional cardiology neighbor last week about tough cases we both had that day that were probably going to keep us up at night.

I'd like to hear more about "ghosts of complications. That adds up..." if you wouldn't mind sharing.

 

[NotAProgDirector]

I'd like to hear more about "ghosts of complications. That adds up..." if you wouldn't mind sharing.

This happens to all of us.

When I was just getting started, I had a patient in the hospital with some inflammatory problem of some sort. I thought I was hot-stuff, thought this was GCA. Told myself I didn't need a biopsy, I was really sure and a negative biopsy wouldn't change my mind (which in GCA is an issue, since the biopsies are relatively low yield and this was long before we were using U/S to target sites). I put her on high dose steroids and BAM! her symptoms got all better. I was really proud of myself. The day before discharge she told me her vision was blurry. I examined her eyes as best I could, everything was fine. I assumed it was nothing. The next AM when I saw her, she was completely blind. I assumed this was GCA (although bilateral would be uncommon). Ophthal saw her urgently, and her eyes were completely WNL. A brain scan demonstrated the problem -- she had bilateral occiptal infarcts. She rapidly decompensated and died three days later. 6 months after that, I'm at M&M conference and as the case unfolds I realize 1) it's her, and 2) something really bad is going to be found that I missed. It's a really horrible feeling. By then, I had made enough mistakes that I was on my way down from Mt. Stupid and joined the discussion pointing out I was caring for her, and I clearly missed something/made an error here. Pathology from autopsy was very definitive -- she had invasive aspergillus everywhere. It's angioinvasive and infarcted her brain. No question that the steroids let it run rampant.

I had a husband and wife in my primary care practice, and my wife and I were somewhat social with them also. The husband got admitted late for something that seemed minor - mild abdominal / back pain. The resident saw them. This was back-in-the-day, so there were no hospitalists. When my patients were admitted, I was the inpatient attending of record. It was late in the PM, I had plans. I asked the resident if they thought they needed me to see them, they felt comfortable. So off to dinner I went. Dinner was interrupted by a page, that my patient was coding. I scrambled back, and he was dead. I took one look at the chart, and the documented marked difference in femoral pulses, and I didn't need an autopsy to tell me what happened. I still wonder if I would have noticed and saved his life had I come in. Telling her he had died and watching her collapse to the ground in tears still haunts me.

The stories go on and on. I expect there are more if you do procedures regularly.

 

[doc.Junior]

This happens to all of us.

When I was just getting started, I had a patient in the hospital with some inflammatory problem of some sort. I thought I was hot-stuff, thought this was GCA. Told myself I didn't need a biopsy, I was really sure and a negative biopsy wouldn't change my mind (which in GCA is an issue, since the biopsies are relatively low yield and this was long before we were using U/S to target sites). I put her on high dose steroids and BAM! her symptoms got all better. I was really proud of myself. The day before discharge she told me her vision was blurry. I examined her eyes as best I could, everything was fine. I assumed it was nothing. The next AM when I saw her, she was completely blind. I assumed this was GCA (although bilateral would be uncommon). Ophthal saw her urgently, and her eyes were completely WNL. A brain scan demonstrated the problem -- she had bilateral occiptal infarcts. She rapidly decompensated and died three days later. 6 months after that, I'm at M&M conference and as the case unfolds I realize 1) it's her, and 2) something really bad is going to be found that I missed. It's a really horrible feeling. By then, I had made enough mistakes that I was on my way down from Mt. Stupid and joined the discussion pointing out I was caring for her, and I clearly missed something/made an error here. Pathology from autopsy was very definitive -- she had invasive aspergillus everywhere. It's angioinvasive and infarcted her brain. No question that the steroids let it run rampant.

I had a husband and wife in my primary care practice, and my wife and I were somewhat social with them also. The husband got admitted late for something that seemed minor - mild abdominal / back pain. The resident saw them. This was back-in-the-day, so there were no hospitalists. When my patients were admitted, I was the inpatient attending of record. It was late in the PM, I had plans. I asked the resident if they thought they needed me to see them, they felt comfortable. So off to dinner I went. Dinner was interrupted by a page, that my patient was coding. I scrambled back, and he was dead. I took one look at the chart, and the documented marked difference in femoral pulses, and I didn't need an autopsy to tell me what happened. I still wonder if I would have noticed and saved his life had I come in. Telling her he had died and watching her collapse to the ground in tears still haunts me.

The stories go on and on. I expect there are more if you do procedures regularly.

Ah, I see. Honestly, it's an honor to hear you share these stories--thank you. Picturing it makes me feel for you in that situation, and I appreciate you taking a moment to relay so openly. I hope I can encounter more stories like this, because there's so much we just hold onto internally and think is unique to us that would be better put in context. ...I've read surgeon Dr Atul Gawande's books, but hearing it from someone who's not a writer makes it hit home more.

 

[eyeeye_captain]

I'd like to hear more about "ghosts of complications. That adds up..." if you wouldn't mind sharing.

Maybe I should have phrased it more as “bad outcomes.” Still adds up.

I’m aware I internalize too much, but I’m a retina surgeon, so any possible f*** ups can lead to blindness with the buck stopping with me. Even though I deal with the sickest of the sick eyes, at a literally microscopic (micron) level, many of which would go blind if myself or my colleagues weren’t around to try, it’s a kick in the gonads every time something goes haywire surgically. You can’t fix them all, but you still have to have the mentality that you can.

Doesn’t mean that you don’t have second guesses at home, no matter if you did your absolute best.

 

[eyeeye_captain]

To change the woe is me narrative, I’ll give my best I saved a life story. MS3. Young individual, BMI of 14, literally unable to eat for a month. Full body rash, but prominent on palms and feet. Presented to a very prominent IM attending that I thought it might be syphilis. Gets an EGD, biopsy comes out gastric syphilis (like <100 cases in the literature at the time).

Bought and brought them the sack of hamburgers they wanted when they passed the swallow study.

 

[Tenk]

I would say being an attending is more fun than being a resident which is more fun than being a medical student but only because you start making money to do fun things.

The actual job portion though definitely gets harder. As you advance you have far more work and responsibility which can cause far more stress for some than just studying and taking tests. This is why it’s important to always have hobbies or things outside of medicine (in particular exercise) so you stay focused on living a good life instead of just work.

 

[HuskyMD Emeritus]

The stress never stops, it's just different. When you have a high ICU census and the ED calls for yet another admission but you have not even finished working on the 1st patient, and the nurses are calling for a central line...... you get the idea. On top of that, if you are involved with administration, that's another level of stress.
The exams also never end. Being good at procrastinating, I elected to take my board recertification exams every 10 years and exam days are definitely stressful (that's 2 exams every 10 years!, very thankful I grandfathered in for the IM boards).
Now that I am semi-retired, work just a few days every couple of weeks, do some admissions interviews, teach at medical school (relearning all the biochem), the stress is a lot less and I'm having a blast.

 

[Dral]

The stories go on and on. I expect there are more if you do procedures regularly.

Yep, I have a few. One that stands out that I won't get into too much is a patient dying of horrible disease a month or so just before their 30th birthday (they told a resident at their appointment before they died that their main goal was to make it to 30). There was nothing that would have been done differently in that patient's case, but seeing someone go through the dying process in their 20s adds stress, especially when it's your patient and there is not much more you can offer to help them avoid dying.

We of course have to move on from these things, but as health care providers we're supposed to be caring people. So we are of course affected by these types of things that happen to patients; and it certainly adds stress to what we do, especially as those experiences add up over the years.

 

[VincentAdultman]

Ah, I see. Honestly, it's an honor to hear you share these stories--thank you. Picturing it makes me feel for you in that situation, and I appreciate you taking a moment to relay so openly. I hope I can encounter more stories like this, because there's so much we just hold onto internally and think is unique to us that would be better put in context. ...I've read surgeon Dr Atul Gawande's books, but hearing it from someone who's not a writer makes it hit home more.

There is a tendency I think (specially among surgeons) to focus on the complications and bad outcomes and forget the patients who praise you and tell you you literally change their lives. I’ve been in pracitcie for a little over ten years (3 hospital employed and 7 in my own practice) and I remember the names of just about all my bad outcomes. As you go on I think you compartmentalize because you have to if you want to do the best job you can. But it never entirely goes away (which is good in my opinion)