Residency struggles

[resident1203]

Hi everyone. PGY1 psych here really struggling with residency.

I’ve always struggled with some subjects in school, particularly maths and sciences, and was always more humanities geared. I managed to get into medical school however, but in medical school I struggled with the firehose of information. I was able to learn and cram things in for tests and Osces and the like and pass, but I don’t really know how much I fully learned or stuck. I’ve had subjective issues with attention longstanding to say the least.

Throughout medical school I also struggled with a lot of imposter syndrome and unconfidence, in part, because it was so tough for information to stick in my head. This made me almost isolate from medical school peers, safe from few very close ones from medical school, but I did not have many study groups that I would be a part of, and took to doing things alone.

I entered into residency this past summer and I hit the ground running, really excited for my specialty. The first few blocks were on service and they went well because the expectations were on the floor and also because I had an attending who held my hand in the first block. The second block I felt I genuinely performed well/to my abilities and was proud of my work at that stage. The next two blocks similarly went well for different reasons until I hit CTU, at which point I realized that my medical knowledge was really lacking. I could handle relatively straightforward cases… but I saw that medical students knew more than I did, and in juggling all of my patients I saw how incredibly disorganized I was. I don’t even want to admit what I didn’t know because it’s so embarrassing. I didn’t want to come into the hospital some days for fear of not assessing a patient correctly, or making a mistake. When I returned to another psych-ish based rotation I found that I was unconfident on service during the day and on call. I realized that I only had 1 more block in psych until I was to become a senior, and was really down on myself about my performance (e.g. my impressions and plan were lacking and disorganized compared to what the senior wrote beneath mine, I was spacing out when patients were talking to me at times, still not sure of how to handle issues on the wards and would reach out to the seniors to get their thoughts, where my peers were not necessarily doing this; struggling to read patient charts and solidify information in my head).

I entered into a bit of burnout and depressed state around this point, and it was pretty bad. I would come home from work and just lie in bed when I got home, waiting to sleep and for the next day to begin. I would go into work hoping that things would be simple and nothing major would happen, lest I not know how to deal with it. There was passive, really bordering on active SI at one point (which was new for me), and that’s when I realized how bad it had gotten. All the things that once brought me such passion and joy and curiosity outside of medicine were consumed by these feelings of inadequacy and unconfidence - I basically forgot who I was… Recognizing all of this, I have been on leave from residency, but despite this time off I still feel in a hole and my nervous system still feels on full alert. I do have a psychiatrist/mental health care team which has been good.

In the past few months I noticed that I would struggle with confidence to sum up my patients fully on rounds (or even remember all their issues), even on simpler rotations. I feel like I have such knowledge deficits myself, I can’t even imagine teaching medical students! (Which will soon be a responsibility).

My question to the forum is: has anyone else (in any specialty) ever found themselves in a place like this? Has it ever gotten better over time? Seeking other stories and words of encouragement. I want to use this time on leave productively so that I return in a better headspace and with more resources and supports than before. And likewise, has anyone ever felt like this and decided to leave residency? Sometimes I honestly don’t see this getting better at all and I feel a sense of calm when I think about leaving clinical medicine. Has anyone felt like this and not been able to perform as a resident (and faced problems with this)?

I’ve been advised by some to seek out an evaluation for ADHD (which I have long suspected and will do), but unfortunately I have a comorbidity where prescribing stimulants is not super advisable.

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[EthylMethylMan]

Throughout medical school I also struggled with a lot of imposter syndrome and unconfidence, in part, because it was so tough for information to stick in my head. This made me almost isolate from medical school peers, safe from few very close ones from medical school, but I did not have many study groups that I would be a part of, and took to doing things alone.

This feeling is very common, and very much natural. You feel like an impostor because you, in fact, are not yet a doctor. It means you're in that middle valley of the Dunning-Kruger curve. It's a humbling experience, and that can be hard to deal with. But since you graduated medical school successfully, it sounds like you've largely handled that situation healthily. Bottom-line is that this doesn't portend becoming a bad doctor.

I entered into residency this past summer and I hit the ground running, really excited for my specialty. The first few blocks were on service and they went well because the expectations were on the floor and also because I had an attending who held my hand in the first block. The second block I felt I genuinely performed well/to my abilities and was proud of my work at that stage. The next two blocks similarly went well for different reasons until I hit CTU, at which point I realized that my medical knowledge was really lacking. I could handle relatively straightforward cases… but I saw that medical students knew more than I did, and in juggling all of my patients I saw how incredibly disorganized I was. I don’t even want to admit what I didn’t know because it’s so embarrassing. I didn’t want to come into the hospital some days for fear of not assessing a patient correctly, or making a mistake. When I returned to another psych-ish based rotation I found that I was unconfident on service during the day and on call. I realized that I only had 1 more block in psych until I was to become a senior, and was really down on myself about my performance (e.g. my impressions and plan were lacking and disorganized compared to what the senior wrote beneath mine, I was spacing out when patients were talking to me at times, still not sure of how to handle issues on the wards and would reach out to the seniors to get their thoughts, where my peers were not necessarily doing this; struggling to read patient charts and solidify information in my head).

Correct me if I'm reading this wrong. It sounds like you started the year doing well in rotations relevant to your specialty. Then you did some inpatient internal medicine and didn't fare so well. This was (understandably) a significant hit to your confidence in your clinical competence. You then returned to psych rotations and your confidence didn't return. Is that right? My follow-up questions would be: How did you do on those later psych rotations? If you did poorly, then why? You say that you did well earlier in the year, so you demonstrated appropriate fund of knowledge and clinical acumen for your level of training. Was the later poor performance purely the bad experience on CTU that took the wind out of your sails and led to you not working as effectively? If all of this stems from feeling inadequate due to being outside of your element, then you should really be easier on yourself. I assume your MS4 year was tailored towards psych. So between that and beginning of intern year, you weren't really doing IM-related things for 14 months. I obviously don't know the details of the knowledge deficits you had on this rotation, but given your likely psych-dominated clinical experiences leading up to this, some lost general medicine knowledge doesn't necessarily reflect poorly on you.

With the information you've given, I don't think you need to be considering leaving residency at this point. At one point, you were at least a good resident. Overall it sounds like you fell into a vicious cycle of: do poorly on rotation -> lose self-confidence -> underperform due to low self-confidence -> do poorly on rotation -> repeat. If this really is the crux of the issue, you need to break the cycle. Doing poorly on an off-service rotation sucks, but doesn't mean you're bad at your primary specialty. You should also definitely continue with counseling. Also, what does your PD think of all this? I presume your PD knows about this situation since you're on leave. Has your PD given any useful input?

With all that said, as mentioned before, please correct anything that I'm misrepresenting here. The more we know about why your performance has dipped, the better advice we can give you.

 

[resident1203]

This feeling is very common, and very much natural. You feel like an impostor because you, in fact, are not yet a doctor. It means you're in that middle valley of the Dunning-Kruger curve. It's a humbling experience, and that can be hard to deal with. But since you graduated medical school successfully, it sounds like you've largely handled that situation healthily. Bottom-line is that this doesn't portend becoming a bad doctor.


Correct me if I'm reading this wrong. It sounds like you started the year doing well in rotations relevant to your specialty. Then you did some inpatient internal medicine and didn't fare so well. This was (understandably) a significant hit to your confidence in your clinical competence. You then returned to psych rotations and your confidence didn't return. Is that right? My follow-up questions would be: How did you do on those later psych rotations? If you did poorly, then why? You say that you did well earlier in the year, so you demonstrated appropriate fund of knowledge and clinical acumen for your level of training. Was the later poor performance purely the bad experience on CTU that took the wind out of your sails and led to you not working as effectively? If all of this stems from feeling inadequate due to being outside of your element, then you should really be easier on yourself. I assume your MS4 year was tailored towards psych. So between that and beginning of intern year, you weren't really doing IM-related things for 14 months. I obviously don't know the details of the knowledge deficits you had on this rotation, but given your likely psych-dominated clinical experiences leading up to this, some lost general medicine knowledge doesn't necessarily reflect poorly on you.

With the information you've given, I don't think you need to be considering leaving residency at this point. At one point, you were at least a good resident. Overall it sounds like you fell into a vicious cycle of: do poorly on rotation -> lose self-confidence -> underperform due to low self-confidence -> do poorly on rotation -> repeat. If this really is the crux of the issue, you need to break the cycle. Doing poorly on an off-service rotation sucks, but doesn't mean you're bad at your primary specialty. You should also definitely continue with counseling. Also, what does your PD think of all this? I presume your PD knows about this situation since you're on leave. Has your PD given any useful input?

With all that said, as mentioned before, please correct anything that I'm misrepresenting here. The more we know about why your performance has dipped, the better advice we can give you.

I think I definitely fell into that cycle that you are mentioning and that is some of it or a large part of it. I appreciate the kindness of your response, and your thoughtfulness in reading what I have posted. Do you have any personal tips or suggestions on how I can break out of this cycle?

But I also sincerely feel that there are other interfering issues at hand too - and there are gaps and deficiencies that I am noticing that are specific to psychiatry as well. I feel like although I felt I was doing well in the beginning, perhaps these were always present and I didn’t worry about them too much then? (I’ll provide some examples below):

For instance, while on psych rotations even in the past (in both medical school and in residency), I would really struggle with reading over and synthesizing admission notes in my head. I would find myself repeating the note over and over again and panicking and trying to read it quickly, telling myself that I wasn't doing things quickly enough. This was something that I was still able to get by with because on admission interview on inpatient units, I'd have a staff or senior resident there to take over the interview to gather information I had not been able to. Additionally, when interviewing a patient, I struggle to keep things in my head unless I write everything down. There’s even some basic DSM-V criteria, that no matter how many times I read over and over again, just won’t stick in my brain. It’s like I keep repeating things over and over again but nothing solidifies, or it takes many many repetitions for it too. I similarly struggled on my last call shift to correctly fill out a form to involuntarily hospitalize a patient - I couldn’t be sure if I was doing it correctly or not.

I also find it hard at times to concentrate on what the patient is saying (especially if their thought process is not organized), synthesize everything they’re telling me, while providing an empathetic response, and making sure that I’m not missing anything and asking everything that I need to. I get in my head and very anxious about whether I’m doing it all right alot and can also struggle with attention, and I think that those things combined interfere with the acquisition of material in front of me.

Most definitely these are issues that I’ve been fixating on recently, since that IM block. And I didn’t notice these deficiencies in the beginning, but I suppose they’re coming to light now. It may be because of the confidence hit, but I do think these are deficiencies that I have - it’s pretty embarrassing to type out if I’m going to be honest.

My PD knows that I am on leave due to burnout, but doesn't know much else - I am hoping to eventually reach out to have a conversation about all of this soon.

 

[DrMetal]

Hi everyone. PGY1 psych here really struggling with residency.

I’ve always struggled with some subjects in school, particularly maths and sciences, and was always more humanities geared. I managed to get into medical school however, but in medical school I struggled with the firehose of information. I was able to learn and cram things in for tests and Osces and the like and pass, but I don’t really know how much I fully learned or stuck. I’ve had subjective issues with attention longstanding to say the least.

Medical school is one of the worst forms of education. It really is a dumb way to learn. It's designed to stress you, to see if you can take it . . .but anybody who knows anything about real education, knows that you really don't learn this way (the firehose approach).

Sadly, this firehose approach continues in residency---perhaps to a lesser degree, b/c residency is a more practical way of learning.

And you know I'm right about the above, b/c when you start practicing, you soon realize how dumb some doctors really are. I've genuinely met some doctors who didn't know insulin is a peptide (that's why it's been hard to make an oral formulation, the pH of your stomach being low enough to break up most small proteins), who didn't know what century WWII was fought in, and who don't know the difference between capitalism and socialism.

Why? Look at how we doctors learn (memorize, take test, answer questions, dump, repeat).

So I wouldn't use medical school as a gauge for anything. In fact, the worse you did in the medical school, the smarter you actually are!

 

[onamission!]

Medical school is one of the worst forms of education. It really is a dumb way to learn. It's designed to stress you, to see if you can take it . . .but anybody who knows anything about real education, knows that you really don't learn this way (the firehose approach).

Sadly, this firehose approach continues in residency---perhaps to a lesser degree, b/c residency is a more practical way of learning.

And you know I'm right about the above, b/c when you start practicing, you soon realize how dumb some doctors really are. I've genuinely met some doctors who didn't know insulin is a peptide (that's why it's been hard to make an oral formulation, the pH of your stomach being low enough to break up most small proteins), who didn't know what century WWII was fought in, and who don't know the difference between capitalism and socialism.

Why? Look at how we doctors learn (memorize, take test, answer questions, dump, repeat).

So I wouldn't use medical school as a gauge for anything. In fact, the worse you did in the medical school, the smarter you actually are!

Most people have no idea how profound and truly correct this is!

 

[operaman]

Some of this is common and some is not. The imposter syndrome is fairly universal and the fact is that as an intern, you really aren't ready to practice without supervision yet and that's ok. Burnout is also quite common, but the amount and duration can vary quite substantially. Personally, I think recognizing you're getting burned out is half the battle, and is still something I occasionally have to battle (and based on multiple studies, something all docs face from time to time as well). I think taking a step back is a wise decision provided you use the time wisely.

I'll share a few pearls that have helped me along the way as far as the headspace goes.

1) You only need to be right about 80% of the time. This goes for exams as much as it goes for clinical medicine. It's easy to get hyperfocused on that last 20% and lose sight of the 80, but content yourself with being wrong a lot. You're going to miss a lot of stuff and make mistakes. The key is structuring your practice so you can catch what you miss eventually, but nobody is perfect. I get sent forms to fill out all the time and I have no idea if I'm doing it right, but I do my best and send it along knowing that someone will let me know if I screwed up.

2) You know the diagnosis 95% of the time before you even step in the room. It's uncommon to get completely undifferentiated patients, so take advantage of the work others have done before you. Keep your questions focused and don't reinvent the wheel.

3) Most of what patients tell you is unimportant. While this runs counter to everything you're taught in med school, it's the honest truth. Don't worry about remembering everything - most of it doesn't matter at all. As you go along, you'll get better at knowing what's actually important.

4) Most of what you tell patients they will forget and/or ignore. Don't waste your time. Keep it succint. One of my attendings in residency would see 60 patients a day in clinic, always ran on time, and left by 5 with all his notes done. He was a beast, but he kept things short and to the point and patients loved him.

5) Patients want a doctor, not a friend. A little empathy is fine, but mostly people want a kind and courteous professional. Don't be afraid to cut people off and redirect them. You'll be amazed at how much most will ultimatly appreciate you for it.

 

[3member]

Remember that you have more responsibilities as a resident than a medical student. You don't have the same luxury hours for study and sleep as they do to focus on the 1-2 patients they pick up along with studying for the rotation. Very normal, you'll get the hang of it

 

[mistafab]

Several thoughts.
1. You made it through med school, so you can make it through residency (most residents do).
2. Biggest factors to not completing residency include 1) physical illness, 2) mental illness, 3) never actually wanted the job (specialty, or doctoring in general). People don't fail because they are dumb. They fail because they are unprofessional, unethical, etc.
3. You're expecting yourself to memorize everything like a computer. Guess what - stop it. Dont remember what the patient says? then write it down. Cant memorize a page of info in the HPI on an admission? Write down key facts. Can't remember the DSM criteria? Guess what, write it down. Go interview the patient with SIGECAPS on your paper if they are depressed, substance use disorder criteria if they are using drugs, ABC criteria for schizophrenia, etc. THat's it. Write down your plan of things to ask, then ask it, and write down the answer.

You'll get better at memorizing stuff if you just get in the flow of having success by any means necessary. You're learning so much every day in residency, it is impossible to remember everything. There are levels to this game. You can do it. Just go one step at a time. Talk with your PD and other attendings or seniors and ask about strategies - share their smart phrases or whatever, and steal their templates. You can even print the template out and walk in the room with it when you talk to patients. There are no rules - do what you need to survive.

In your time off, I would just make sure you take care of any lingering mental illness if that is present.

 

[dozitgetchahi]

I think I definitely fell into that cycle that you are mentioning and that is some of it or a large part of it. I appreciate the kindness of your response, and your thoughtfulness in reading what I have posted. Do you have any personal tips or suggestions on how I can break out of this cycle?

But I also sincerely feel that there are other interfering issues at hand too - and there are gaps and deficiencies that I am noticing that are specific to psychiatry as well. I feel like although I felt I was doing well in the beginning, perhaps these were always present and I didn’t worry about them too much then? (I’ll provide some examples below):

For instance, while on psych rotations even in the past (in both medical school and in residency), I would really struggle with reading over and synthesizing admission notes in my head. I would find myself repeating the note over and over again and panicking and trying to read it quickly, telling myself that I wasn't doing things quickly enough. This was something that I was still able to get by with because on admission interview on inpatient units, I'd have a staff or senior resident there to take over the interview to gather information I had not been able to. Additionally, when interviewing a patient, I struggle to keep things in my head unless I write everything down. There’s even some basic DSM-V criteria, that no matter how many times I read over and over again, just won’t stick in my brain. It’s like I keep repeating things over and over again but nothing solidifies, or it takes many many repetitions for it too. I similarly struggled on my last call shift to correctly fill out a form to involuntarily hospitalize a patient - I couldn’t be sure if I was doing it correctly or not.

I also find it hard at times to concentrate on what the patient is saying (especially if their thought process is not organized), synthesize everything they’re telling me, while providing an empathetic response, and making sure that I’m not missing anything and asking everything that I need to. I get in my head and very anxious about whether I’m doing it all right alot and can also struggle with attention, and I think that those things combined interfere with the acquisition of material in front of me.

Most definitely these are issues that I’ve been fixating on recently, since that IM block. And I didn’t notice these deficiencies in the beginning, but I suppose they’re coming to light now. It may be because of the confidence hit, but I do think these are deficiencies that I have - it’s pretty embarrassing to type out if I’m going to be honest.

My PD knows that I am on leave due to burnout, but doesn't know much else - I am hoping to eventually reach out to have a conversation about all of this soon.

Just a few remarks based on what you’ve been saying:

- I wouldn’t be too concerned about the IM blocks you’re doing as an intern, especially if you’ve been put on hardcore rotations like CCU. When I was an IM resident and we had psych interns rounding with us, honestly our expectations were relatively low - we knew those folks were there to do their time and move along to what they’re really training for (psych). As long as you put in a good faith effort there and weren’t lazy, I honestly think you’re OK. If you can’t remember hardcore IM stuff, don’t worry about it - pretty soon you’ll be moving on to psych and you won’t focus on this stuff again. You’re not an IM intern.

- You’re going to get this stuff more and more as you do more of it. There were times where I felt like you at every phase of training - keep reading and also don’t try to rely on memory for everything. For instance, if you do a consult print out your note and use it to present (hell, even just read out your note if you must). When I was on nightmare overnight call shifts and had to present 8 new admissions in the AM, this is honestly how I would do it - print notes, write in other details or new lab results as you must, and just roll. It doesn’t have to be perfect. You may be tripping yourself up by trying to make everything extremely polished. As a resident, it’s not always going to be. If you’re presenting, say, a crashing patient in the ICU, the point is to get the most important and pertinent facts across quickly.

- Paperwork is basically bull****. Whenever random paperwork was dumped on me as a trainee, I basically just filled it out as best I could and if I didn’t hear anything about it later…it’s good enough for government work. A lot of BS medical paperwork is just silly and there’s not always even a “correct” way to do it. Put down what you know and move on.

 

[clausewitz2]

OP, one thing I'm not seeing in your account of all this is whether your seniors or attendings have expressed any concerns to you or noted any deficiencies. How much is this a problem that people external to your skull are aware of?

 

[Redpancreas]

Hi everyone. PGY1 psych here really struggling with residency.

I’ve always struggled with some subjects in school, particularly maths and sciences, and was always more humanities geared. I managed to get into medical school however, but in medical school I struggled with the firehose of information. I was able to learn and cram things in for tests and Osces and the like and pass, but I don’t really know how much I fully learned or stuck. I’ve had subjective issues with attention longstanding to say the least.

Throughout medical school I also struggled with a lot of imposter syndrome and unconfidence, in part, because it was so tough for information to stick in my head. This made me almost isolate from medical school peers, safe from few very close ones from medical school, but I did not have many study groups that I would be a part of, and took to doing things alone.

I entered into residency this past summer and I hit the ground running, really excited for my specialty. The first few blocks were on service and they went well because the expectations were on the floor and also because I had an attending who held my hand in the first block. The second block I felt I genuinely performed well/to my abilities and was proud of my work at that stage. The next two blocks similarly went well for different reasons until I hit CTU, at which point I realized that my medical knowledge was really lacking. I could handle relatively straightforward cases… but I saw that medical students knew more than I did, and in juggling all of my patients I saw how incredibly disorganized I was. I don’t even want to admit what I didn’t know because it’s so embarrassing. I didn’t want to come into the hospital some days for fear of not assessing a patient correctly, or making a mistake. When I returned to another psych-ish based rotation I found that I was unconfident on service during the day and on call. I realized that I only had 1 more block in psych until I was to become a senior, and was really down on myself about my performance (e.g. my impressions and plan were lacking and disorganized compared to what the senior wrote beneath mine, I was spacing out when patients were talking to me at times, still not sure of how to handle issues on the wards and would reach out to the seniors to get their thoughts, where my peers were not necessarily doing this; struggling to read patient charts and solidify information in my head).

I entered into a bit of burnout and depressed state around this point, and it was pretty bad. I would come home from work and just lie in bed when I got home, waiting to sleep and for the next day to begin. I would go into work hoping that things would be simple and nothing major would happen, lest I not know how to deal with it. There was passive, really bordering on active SI at one point (which was new for me), and that’s when I realized how bad it had gotten. All the things that once brought me such passion and joy and curiosity outside of medicine were consumed by these feelings of inadequacy and unconfidence - I basically forgot who I was… Recognizing all of this, I have been on leave from residency, but despite this time off I still feel in a hole and my nervous system still feels on full alert. I do have a psychiatrist/mental health care team which has been good.

In the past few months I noticed that I would struggle with confidence to sum up my patients fully on rounds (or even remember all their issues), even on simpler rotations. I feel like I have such knowledge deficits myself, I can’t even imagine teaching medical students! (Which will soon be a responsibility).

My question to the forum is: has anyone else (in any specialty) ever found themselves in a place like this? Has it ever gotten better over time? Seeking other stories and words of encouragement. I want to use this time on leave productively so that I return in a better headspace and with more resources and supports than before. And likewise, has anyone ever felt like this and decided to leave residency? Sometimes I honestly don’t see this getting better at all and I feel a sense of calm when I think about leaving clinical medicine. Has anyone felt like this and not been able to perform as a resident (and faced problems with this)?

I’ve been advised by some to seek out an evaluation for ADHD (which I have long suspected and will do), but unfortunately I have a comorbidity where prescribing stimulants is not super advisable.

Completely agree with the above response, especially given OP says he/she has some imposter syndrome component, but I will just assume this is not in OPs head given he/she has been recommended to receive evaluation for ADHD and because it seems that OPs mood and clinical ability are interrelated which wouldn't be the case if OP was just suffering from a mental health issue.

It sounds like there are multiple significant deficiencies include organization skills and maybe medical knowledge. There will also be a deficit in clinical reasoning (separate from medical knowledge) because you can not even begin to practice that without having a solid grasp of the procedural tasks and basic medical knowledge required of your specialty. On top of all this, it seems like you're suffering with a mood disorder that your personality traits have predisposed you to and it has been exacerbated by the deficits in your performance which have probably been brought to your attention.

Unfortunately, the first thing to do is to start with the mental health. I don't like to speculate, but it sounds like you carry some sort of bipolar depression hx. based on the statement you made about contraindications to stimulants. That's a significant barrier. Even if you don't have that and have something else like ADHD + Congenital Heart Disease, you need to get that evaluated by a psychiatric professional and ensure you're receiving the standard of care. It sounds like a tough situation, but what I like to think in these cases is that perfect is the enemy good. It sounds like you're not taking any steps to address your mental health issues so doing anything should make some difference. Drag yourself mentally to make an appointment and keep it. Most residencies are pretty flexible about you taking an afternoon off for a medical appointment. You will only see improvement after a few months as you very well know given you are literally in psychiatry residency.

The next step is unclear because I am not sure to what extent you are deficient in medical/psychiatry knowledge. Sometimes medical students have just reviewed Step 1/2 information so their question-answering reflexes are primed so I wouldn't use that as a barometer of your basic medical knowledge. How did you do on Step 1, 2CK, 3, the In-Training-Exam? These are by far better predictors of medical knowledge that situational circumstances. If you did somewhere near average or well, I wouldn't worry too much about medical knowledge. If you did very poorly (<25% percentile) then you will need to purchase some sort of high quality, up to date psychiatry board review. Talk to seniors to figure out what the best ones are. Every night, I would recommend spending 30 minutes watching a video or reviewing a chapter and using spatial repetition processes (flash cards, ANKI, questions) to consolidate these concepts.

The most important thing in all of this though it to figure out how you're going to organize yourself as this is probably going to be the biggest barrier to your overall success. One thing I would suggest is to consolidate your methods. You need to discipline yourself to start chart reviewing, seeing patients, and doing interviews the same way every day. This makes you more efficient at your tasks and makes you less susceptible to missing things. Most importantly, you will overtime naturally gain efficiency which will then allow you to use more of your bandwidth on clinical reasoning which, succinctly stated, is recognizing which subjective/objective data points ought to be weighed the most to make accurate diagnoses and effective treatment plans. Rinse & Repeat...

 

[dozitgetchahi]

Completely agree with the above response, especially given OP says he/she has some imposter syndrome component, but I will just assume this is not in OPs head given he/she has been recommended to receive evaluation for ADHD and because it seems that OPs mood and clinical ability are interrelated which wouldn't be the case if OP was just suffering from a mental health issue.

It sounds like there are multiple significant deficiencies include organization skills and maybe medical knowledge. There will also be a deficit in clinical reasoning (separate from medical knowledge) because you can not even begin to practice that without having a solid grasp of the procedural tasks and basic medical knowledge required of your specialty. On top of all this, it seems like you're suffering with a mood disorder that your personality traits have predisposed you to and it has been exacerbated by the deficits in your performance which have probably been brought to your attention.

Unfortunately, the first thing to do is to start with the mental health. I don't like to speculate, but it sounds like you carry some sort of bipolar depression hx. based on the statement you made about contraindications to stimulants. That's a significant barrier. Even if you don't have that and have something else like ADHD + Congenital Heart Disease, you need to get that evaluated by a psychiatric professional and ensure you're receiving the standard of care. It sounds like a tough situation, but what I like to think in these cases is that perfect is the enemy good. It sounds like you're not taking any steps to address your mental health issues so doing anything should make some difference. Drag yourself mentally to make an appointment and keep it. Most residencies are pretty flexible about you taking an afternoon off for a medical appointment. You will only see improvement after a few months as you very well know given you are literally in psychiatry residency.

The next step is unclear because I am not sure to what extent you are deficient in medical/psychiatry knowledge. Sometimes medical students have just reviewed Step 1/2 information so their question-answering reflexes are primed so I wouldn't use that as a barometer of your basic medical knowledge. How did you do on Step 1, 2CK, 3, the In-Training-Exam? These are by far better predictors of medical knowledge that situational circumstances. If you did somewhere near average or well, I wouldn't worry too much about medical knowledge. If you did very poorly (<25% percentile) then you will need to purchase some sort of high quality, up to date psychiatry board review. Talk to seniors to figure out what the best ones are. Every night, I would recommend spending 30 minutes watching a video or reviewing a chapter and using spatial repetition processes (flash cards, ANKI, questions) to consolidate these concepts.

The most important thing in all of this though it to figure out how you're going to organize yourself as this is probably going to be the biggest barrier to your overall success. One thing I would suggest is to consolidate your methods. You need to discipline yourself to start chart reviewing, seeing patients, and doing interviews the same way every day. This makes you more efficient at your tasks and makes you less susceptible to missing things. Most importantly, you will overtime naturally gain efficiency which will then allow you to use more of your bandwidth on clinical reasoning which, succinctly stated, is recognizing which subjective/objective data points ought to be weighed the most to make accurate diagnoses and effective treatment plans. Rinse & Repeat...

I basically agree with this, although I will say this: from reading posts here, I can’t tell how much of the OPs troubles are real or just perceived. As a resident, I absolutely remember working with sub-is and medical students who were smart and well read but who would get nervous and psych themselves out when trying to present or answer attendings’ pimp questions etc - they would sometimes come across as less capable than they actually were.

Also, medical students come out of medical school variably prepared for certain specialties vs others. Medical school overwhelmingly focuses on general medicine; a fresh intern in July may be relatively well prepped for FM or IM, but know practically nothing about ortho, optho, rad onc, anesthesiology, etc. Psych, in my opinion, is closer to being one of these “know practically nothing” specialties than, say, IM. It’s a very different arena than most other specialties of medicine. My suspicion is that fresh psych interns aren’t expected to be geniuses from day one - there’s probably a lot of handholding and guidance for at least the first year. OP has done only a couple of psych rotations interspersed with CCU, which has practically nothing to do with psych. He/she is still just getting warmed up, and unless he actually really doesn’t know which end is up, I think he’s probably doing better than he suspects.