Still feel like I don't know what I'm doing as a fourth year

[SierraMist14]

Hey all. I'm currently in my fourth year, applying for residency. I've been feeling really bummed lately as I feel like I still don't have a good grasp on managing patients. I'm still struggling with my assessments and plans and it's starting to discourage me. In particular, I'm having trouble on wards (IM). I'm not going into IM, but I'm going into a specialty which will require a prelim year in medicine. Granted I haven't presented a patient in almost 3 months, I still feel like I should be doing better than I am. Some things I'm still having trouble with:

1. Not so much having an A/P, but organizing and saying it in a way that the attending is pleased with. For example, not saying the most important information first. All of the information is there, but sort of scattered. How do you guys approach writing your A/P? System-based or problem based? Still sure which one is easier for me.

2. I don't have a great memory and I get flustered when I have so much information to remember at once. For example, if I'm given a new patient and have to learn everything about their past history in their chart. I will read the information but I wont remember it. And when the attending asks me about it I end up looking like an idiot. This scares me because I struggle with just a few patients; I don't know how I will handle a dozen patients at once.

3. Just presenting confidently period. I get so nervous when I present that I kind of rush through things. I try my best to present without notes and when I have to look down at them I get scowled at for "not knowing my patient."

There just seems to be SOMETHING I forget or don't do no matter how hard I try! Any tips? Words of encouragement?

Thanks guys!

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[GimpGenius]

All of this is anecdotal, so take it for what it's worth.

1. Every attending (and every service) is going to be different. A/P in my world is based on "what's the most serious problem" first, moving down the line. Chronic, controlled HTN isn't as high on the list as that PE the patient's recovering from. At some point, the minor stuff (controlled issues, long-standing PCP-based medical concerns) aren't in any particular order. N = 1, of course. Finding what you're comfortable with will help with #3.

2. Notes, notes, notes, and more notes. I can't keep patients straight, so I usually have a rounding list or a folded sheet of paper with pt info on it. The whole concept of "I don't take notes, ever" is beyond me, personally; and I'd rather take notes and have an attending think I'm an idiot than not take notes, give bad info, be an idiot, and potentially endanger a patient.

3. Deep breath. Ask for feedback from attendings/residents. In general, new patients should take you longer to present; someone on day 8, who's waiting on consults/sign-offs from other services, may just be "this is Mr. X, here for seven days, no issues overnight, *summary of any consults*, changes in labs, plan for discharge after Y service consult/sign off."

Most important thing: You're still learning. Even a fresh attending has 3+ years on you; more encounters, more hours, more everything. Learn what you can, have realistic expectations of yourself (and of your preceptors), and adapt those lessons to how you practice.

 

[NontradICUdoc]

Wait until you are an intern, then you will really know what it is like to not know anything. For some reason, once you start as an intern you tend to forget things because of your anxiety that you are the actual doc and people are coming to you for orders. Relax, it will pass and you will be more confident. It comes with time.

 

[Ismet]

I always found it beneficial to ask the attending if they like presentations to be in a certain way. Works out better than doing it wrong the first time and having to prove yourself the second time.

 

[image187]

I say don't sweat it. You probably know a lot more than you think you do as a 4th year at this point, but things will most likely start to click and confidence start to build during intern year when you actually need to think about your patients all the time and you learn them inside-and-out without even realizing it.

If 4th years had a "good grasp on managing patients" then I don't think residency would be so stressful or even required. Cheers to making it this far. My 2 cents

 

[cabinbuilder]

Not to worry. I went into intern year with not really ever doing and H&P or having any good medicine rotations. Intern year is a huge learning curve and it does get better.

 

[572776]

Not to worry. I went into intern year with not really ever ding and H&P or having any good medicine rotations. Intern year is a huge learning curve and it does get better.

I'm in the same boat as OP. ^this makes me feel a lot better. Thank you.

 

[Doctor Bagel]

Hey all. I'm currently in my fourth year, applying for residency. I've been feeling really bummed lately as I feel like I still don't have a good grasp on managing patients. I'm still struggling with my assessments and plans and it's starting to discourage me. In particular, I'm having trouble on wards (IM). I'm not going into IM, but I'm going into a specialty which will require a prelim year in medicine. Granted I haven't presented a patient in almost 3 months, I still feel like I should be doing better than I am. Some things I'm still having trouble with:

1. Not so much having an A/P, but organizing and saying it in a way that the attending is pleased with. For example, not saying the most important information first. All of the information is there, but sort of scattered. How do you guys approach writing your A/P? System-based or problem based? Still sure which one is easier for me.

2. I don't have a great memory and I get flustered when I have so much information to remember at once. For example, if I'm given a new patient and have to learn everything about their past history in their chart. I will read the information but I wont remember it. And when the attending asks me about it I end up looking like an idiot. This scares me because I struggle with just a few patients; I don't know how I will handle a dozen patients at once.

3. Just presenting confidently period. I get so nervous when I present that I kind of rush through things. I try my best to present without notes and when I have to look down at them I get scowled at for "not knowing my patient."

There just seems to be SOMETHING I forget or don't do no matter how hard I try! Any tips? Words of encouragement?

Thanks guys!

Unless you're getting outside feedback that you're not doing poorly, I suspect you're doing much better than you think you are. You're still really new to this, and you should be struggling with this stuff. You've still got years and years of training left to figure these things out.

It sounds like you'll be able to do a better job if you take more time to write things down before presenting -- it sucks because it eats more time, but it's totally OK to need that, especially at this time in your training. And why not reference your notes when presenting? It might be more a matter of making sure your notes are in order, so you're not scouring them to find the information -- instead you look down, and it's right where you expected it.

About synthesizing all the information -- you'll realize that there's so much information available now that no one is picking up on all of it. Feeling like you're missing important details all the time is pretty much how it is these days. Now figuring out how not to miss things that could kill people gets easier, but yeah, there's always going to be some detail in someone's history that's missed. Things to EMR and information overload, that's just how it is.

Other good news -- once you're an attending, you won't have to present on rounds.

 

[dienekes88]

Hey all. I'm currently in my fourth year, applying for residency. I've been feeling really bummed lately as I feel like I still don't have a good grasp on managing patients. I'm still struggling with my assessments and plans and it's starting to discourage me. In particular, I'm having trouble on wards (IM). I'm not going into IM, but I'm going into a specialty which will require a prelim year in medicine. Granted I haven't presented a patient in almost 3 months, I still feel like I should be doing better than I am. Some things I'm still having trouble with:

1. Not so much having an A/P, but organizing and saying it in a way that the attending is pleased with. For example, not saying the most important information first. All of the information is there, but sort of scattered. How do you guys approach writing your A/P? System-based or problem based? Still sure which one is easier for me.

2. I don't have a great memory and I get flustered when I have so much information to remember at once. For example, if I'm given a new patient and have to learn everything about their past history in their chart. I will read the information but I wont remember it. And when the attending asks me about it I end up looking like an idiot. This scares me because I struggle with just a few patients; I don't know how I will handle a dozen patients at once.

3. Just presenting confidently period. I get so nervous when I present that I kind of rush through things. I try my best to present without notes and when I have to look down at them I get scowled at for "not knowing my patient."

There just seems to be SOMETHING I forget or don't do no matter how hard I try! Any tips? Words of encouragement?

Thanks guys!

Where I went to medical school, it was old school. I presented all my Medicine H&Ps from memory. That made it even more important to make a coherent story, because otherwise it was impossible to memorize. I figured that out the hard way. Many times.

I also now dictate most of my H&Ps and consultation reports (and operative reports for that matter), because it forces me to have a lot of the information in my head concurrently and I have to tell a story that makes sense. I find that dictated notes are typically better than the pre-populated stuff with a brief typed out HPI.

As for presenting confidently, it comes with experience. You have to put your nickel down. At the beginning, you're going to be wrong. A lot. Because you don't know much medicine. However, if you keep putting your nickel down on what you think the diagnosis is (after coming up with an appropriate differential diagnosis), you're going to be right more and more often.

Looking like an idiot... it's part of life. It's part of medicine. It's part of training. That's why you're a resident. There'll be things that you have never seen and therapies you couldn't have even dreamed of... but these will be your patients, and you'll have to read a couple articles and try to make sense of it all to create a coherent plan of care.

This process is what separates us from the PAs and NPs.

 

[HooliganSnail]

Patient presentations are all about brevity. You never really understand what it is like to listen to a long drawn out boring presentation until you have to take one from a med student yourself, then you will get it.

Lead with diagnosis, or at least get there quickly

"Mrs S is a 76 F in for acute exacerbation of systolic CHF"

Then talk BRIEFLY about her symptoms on presentation

"She has been complaining of progressive SOB worse over the past 4 days, and more swelling in her legs"

Then talk BREIFLY about what has been done for her and what the plan for her is

"She is on 80mg Lasix BID, fluid and salt restriction, and we started Imdur this AM. An echo is planned for this AM. Her last echo was .....and it showed......"

BAM. Three sentences and you have given the attending the story.

The keys are such

1. Give them a brief presentation, but know all of the details. The attending will ask you what they want to know. Let them decide who details they want. You just need to know them.

2. You will get better at understanding what details are important as you do more of these cases. No one cares what she had for breakfast. Also it is not necessary to report that an IV was started ( NO duh)

3. Seriously, you should approach a presentation as if you have three statements to get him the major points of the story. Everything else is just filler

 

[JustPlainBill]

Not to worry. I went into intern year with not really ever doing and H&P or having any good medicine rotations. Intern year is a huge learning curve and it does get better.

Yep -- In intern year, I actually had to go download an H&P to remember WTF was in one and doing the A&P was agonizing -- I'll never forget the day that I was on over the weekend during a ward month early in my intern year and the PD happened to be on that weekend. As I'm presenting a CHF patient, he looks at me and asks what her weight was today vs yesterday -- I'm looking at him like "Why are you asking?" -- he just casually stated," You aren't tracking weights in a CHF exac on Lasix?" -- and no, I hadn't reported I/Os-- you learn through repetition and mistakes -- the seniors should be teaching you and keeping you from killing someone --- this continues out into clinic practice as an attending --- I still regularly contact SDN colleagues to commiserate and run cases by them when I'm not sure -- I've also got senior partners who've been doing this for 30 years that I'll ask intricate management questions to or some system based thing that is peculiar -- repetition and properly supervised practice is the mother of skill --- There's a pocket book out by a guy named Paul Chan (Titled Family medicine)-- little blue book -- has the H&P for the most common admitting Dx in FM -- peruse it to see if it helps you with what labs, what tx, etc.

Do not sweat this -- you are just like everyone else -- do not get so anxious that you vapor-lock your brain and get flustered -- relax and present like you would to a colleague. Accept criticism in stride and try to do better next time -- you really don't know if they were scowling at you or trying to pass gas without making a noise, right? Assume the latter ----

the key thing I want you to take away from this: YOU DO NOT HAVE TO KNOW EVERYTHING -- you just have to know where to look it up -- also "I don't know" by itself is not acceptable -- "I don't know right now, let me check on that and I'll get back to you" -- is the right answer -- it's a positive spin and shows motivation.....

relax -- and remember half of your class is below average ;->

 

[Jimmy B]

You'll have the same experience the first day of intern year, except this time you'll actually be responsible for patient care. Your upper level residents will help you out as you move along.

 

[PL198]

Patient presentations are all about brevity. You never really understand what it is like to listen to a long drawn out boring presentation until you have to take one from a med student yourself, then you will get it.

Lead with diagnosis, or at least get there quickly

"Mrs S is a 76 F in for acute exacerbation of systolic CHF"

Then talk BRIEFLY about her symptoms on presentation

"She has been complaining of progressive SOB worse over the past 4 days, and more swelling in her legs"

Then talk BREIFLY about what has been done for her and what the plan for her is

"She is on 80mg Lasix BID, fluid and salt restriction, and we started Imdur this AM. An echo is planned for this AM. Her last echo was .....and it showed......"

BAM. Three sentences and you have given the attending the story.

The keys are such

1. Give them a brief presentation, but know all of the details. The attending will ask you what they want to know. Let them decide who details they want. You just need to know them.

2. You will get better at understanding what details are important as you do more of these cases. No one cares what she had for breakfast. Also it is not necessary to report that an IV was started ( NO duh)

3. Seriously, you should approach a presentation as if you have three statements to get him the major points of the story. Everything else is just filler

that's your preference though, then there are attendings where their(patient's) hemoglobin is 12 and that's like the 15th thing on their problem list but they still want you to talk about why you don't need to give blood

 

[HooliganSnail]

that's your preference though, then there are attendings where their(patient's) hemoglobin is 12 and that's like the 15th thing on their problem list but they still want you to talk about why you don't need to give blood

That is the big point of this whole thing. You know the Hgb is 12, if he wants to know about it, he can ask.

It is not just my preference, it is generally the preference of most attendings and consultants. If you want, you can continue to give long winded presentations that include a mild anemia which has limited if any clinical reference and bore the pants off of everyone involved.....

 

[PL198]

That is the big point of this whole thing. You know the Hgb is 12, if he wants to know about it, he can ask.

It is not just my preference, it is generally the preference of most attendings and consultants. If you want, you can continue to give long winded presentations that include a mild anemia which has limited if any clinical reference and bore the pants off of everyone involved.....

that was the whole point of my post. I've encountered more attendings that want the long winded literally everything like their chloride is 1 eq low, than I have that want the short and sweet. I completely agree it's not clinically relevant and boring but they will b*tch if you don't do it.

I was saying if the hgb is 12, they expect you to mention it and go into a differential and plan regarding it. I don't want to do that, but it's what most of the attendings I've been with so far want.

 

[Siggy]

1. Not so much having an A/P, but organizing and saying it in a way that the attending is pleased with. For example, not saying the most important information first. All of the information is there, but sort of scattered. How do you guys approach writing your A/P? System-based or problem based? Still sure which one is easier for me.

As an internal medicine resident, I go by problem based. In general, I list the active problem(s) first (1. Septic shock 2/2 pneumonia 2. Community Acquired Pneumonia... etc), then active inpatient issues (e.g. electrolytes, PMH issues actively being managed, etc), and then chronic history problems that the patient is still taking medications for. However, this is fluid. For an admission, problem number 1 is generally the chief complaint with the differentials listed (i.e. 1. Shortness of breath 2/2 PNA vs bronchitis vs asthma vs...). Also chronic medical problems can often show up in the first 1 or 2 issues if it's a contributing factor (i.e. 1. DKA 2. DM type 1 uncontrolled with neurological manifestations).

2. I don't have a great memory and I get flustered when I have so much information to remember at once. For example, if I'm given a new patient and have to learn everything about their past history in their chart. I will read the information but I wont remember it. And when the attending asks me about it I end up looking like an idiot. This scares me because I struggle with just a few patients; I don't know how I will handle a dozen patients at once.

It gets better. I remember when I wasn't able to rattle off lab values on admits (and I often still can't). So I either write them down or have a computer open when I present to the attending.

3. Just presenting confidently period. I get so nervous when I present that I kind of rush through things. I try my best to present without notes and when I have to look down at them I get scowled at for "not knowing my patient."

Practice, practice. practice. Again, it gets better.

There just seems to be SOMETHING I forget or don't do no matter how hard I try! Any tips? Words of encouragement?

Thanks guys!

If you were never forgetting anything, then why would you need residency?

 

[styphon]

1. Not so much having an A/P, but organizing and saying it in a way that the attending is pleased with. For example, not saying the most important information first. All of the information is there, but sort of scattered. How do you guys approach writing your A/P? System-based or problem based? Still sure which one is easier for me.

2. I don't have a great memory and I get flustered when I have so much information to remember at once. For example, if I'm given a new patient and have to learn everything about their past history in their chart. I will read the information but I wont remember it. And when the attending asks me about it I end up looking like an idiot. This scares me because I struggle with just a few patients; I don't know how I will handle a dozen patients at once.

3. Just presenting confidently period. I get so nervous when I present that I kind of rush through things. I try my best to present without notes and when I have to look down at them I get scowled at for "not knowing my patient."

I am entering my 3rd year as an attending and sometimes I still feel like I don't know much, I think it is a good recognition of the massive amount of information that is constantly changing. Thinking you know everything is where someone can get in trouble.

1. The A/P order will depend on what rotation you are on. Examples:
-The ER usually wants problem based, ranked by most deadliest first
-ICU's usually do system based
-Medical floors usually do problem based, usually based on severity/reasons for admission first.

2. Write things down. Keep organized notes in short hand. I used a sheet of paper divided into sections when I was a resident, others used little notebooks, others used a note card per patient, others used an IPAD or similar device.

3. Confidence comes with experience. Before presenting take a deep breath, calm yourself down. Then go in an order, and stick to that order for that rotation. For example, on floors for new admits you can do CC, HPI, PMH, PSH, MEDS, ROS, PE, A/P. Stick to the order, which will help you keep organized. Ask for experience from seniors, maybe you could do a mock patient presentation to them and they could help you mold it correctly and point out the weak points.

 

[HooliganSnail]

that was the whole point of my post. I've encountered more attendings that want the long winded literally everything like their chloride is 1 eq low, than I have that want the short and sweet. I completely agree it's not clinically relevant and boring but they will b*tch if you don't do it.

I was saying if the hgb is 12, they expect you to mention it and go into a differential and plan regarding it. I don't want to do that, but it's what most of the attendings I've been with so far want.

I have never once met an attending who is like that, and any attending like that would be the absolute worst to round with. Rounding must take hours and hours.

I feel for you.

Otherwise, the whole brevity is the soul of wit thing will serve you well as you advance through the hierarchy

 

[Siggy]

I have never once met an attending who is like that, and any attending like that would be the absolute worst to round with. Rounding must take hours and hours.

"10. Normocytic anemia (slight)
-Monitor."


There, 3 seconds and it's taken recognized and everyone can continue to not care about it.