Stressed out already!

[danvasta]

I wonder if other interns are going through this or is it just me? I'm totally lost even on an easy rotation it took me 30 mins to finish a note today and an hour to see the patient, in the clinic! I feel like I've forgotten alot of things including basic history taking(I hadn't seen a patient since last year), I miss things I really shouldn't be missing. And I KNOW its not because I don't know anything, I do. If the attending asks me something I usually get it right but just the logistics including just getting to know the EMR, not knowing where to go etc and on top of that having to study for an in training, all of it is just overwhelming. Guys how do I get better? Does it get better ?

---

Members don't see this ad.

 

[danvasta]

I've never felt like such a complete idiot. And the funny thing is, I know I'm not an idiot. I just don't know how to get better!

 

[WonderBoy]

It gets better. Honestly, I took me until october-november to get used to everything. I had never even used the EMR we had, it really sucked the first few months. Accept that you don't know much, ask for help and always say thank you. You will be fine.

 

[anaesthetic]

.

 

[Trogghunter]

You're off service.... no one will ever remember or care. Just see patients.

 

[gutonc]

Even if you're doing a core in your specialty, the only thing people will remember about this month is how much better you are when they see you doing it again in November, and then in March.

 

[danvasta]

I agree, I feel like much of intern year is less about medical knowledge and just knowing how things get done in the hospital aka being efficient! And med school does NOT prepare you for that.

 

[belial20042002]

I am neurology and I worked in ED for 7 days. i feel like the worst intern in the history of residency. The learning curve is so steep I feel I should just quit residency all together. So disappointed at myself.

 

[Crayola227]

At this point in the year, this is totally normal. Keep bugging your uppers. If they ask you how long you've been there, say _ weeks but stop when it's been 2 mos. Preface things saying, "never done this before" when it's a system issue like printing an Rx or something like that. If there's ever a lull, like end of day with notes or something, ask the upper how you can be more efficient. If you half-ass through something when you're busy and they can't help you, so be it, just keep that in mind and ask them later when they're less likely to bite your head off. They want you to do it better (aka faster and with less input from them) next time, and when the dust settles they know helping you is helping themselves.

You're exhausted at the end of the day, and they can track your work hours through when you've signed your last note or order, but after that, as long as you are not signing anything, you can play in the EHR reading and it doesn't count towards hours. Make yourself spend a little time at the end of the day ****ing around in it clicking places finding where stuff is. Make templates that will help you be faster. This little investment of time when you're not under the gun will help your efficiency.
Make order sets to make certain often used orders faster to put in, like a bowel regimen or repleting 'lytes

I use mneumonics to save brain power for my H&Ps, like OLD CARTS and PMASF.
I was taught a trick that doing HPI, PMHx, and then med rec (which will help you fill in the patient's blanks on PMHx by reverse engineering meds to dz) helps you get the basic admit orders in quick before they get moved from the ED to the floor if that's were you're headed, then follow it upstairs with allergies, soc hx, fam hx to fill in the blanks for your notes. There's a lot of orders you can get in without addressing why they're there until you can talk with an upper or attending, then you only have to add final touches.
Scut sheets for values and something to quickly jot down PE findings helps me. Get good at organizing your data and to do's.
For any rotation I google to find a survival guide for it, something aimed at interns not med students.
EM Resident Association has a book Top Clinical Problems in EM online has helped me lots in all hospital rotations so I'm sure I've thought about stuff that kills poeple, the ddx, w/u, and basic plan. It's great for ED and nightfloat, and doesn't hurt on the wards either

Read my other posts about intern stuff.

Just really work at being fast, getting notes done as quickly as possible, making love to your pager, and being as likable as you can keep your head down.

I felt like jumping off the hospital every day walking from the parking garage and to the parking garage at work in the beginning. I cheered myself up telling myself that a ****ty resident helps the program more than a dead resident, so every day that you live and show up is doing a great service to the program. Pat yourself on the back for not quitting. Sounds sick, but it made me feel a little better when I was totally incompetent. Every note and page and order that you do is less work for someone else, keep your presentations organized and short, and you are less of an annoyance than you think you are to your uppers.

99% of all interns are crying on an almost daily basis for like the first 1/3 of the year. It is normal and you are not alone. Don't kill yourself. Seriously.

Keep some calories on you at all times, even if it's just a sugar packet, and some caffiene like the little bottle shots or caffeine pills, and APAP/NSAID for aches/pains. Keeping the machine as oiled and fueled as you can helps tons. Make sleeping and eating the most important home activities if you can (easier to do if you don't have children).

Do something about getting yourself to sleep when you're on nightfloat. You need a dark room and melatonin. I've known people to sleep in their closet to get a little darkness on nightfloat.

 

[Crayola227]

When you were a med student, as a member of the team that needed to be the silent mouse not getting in the way, you felt like you never wanted to interrupt an upper on the computer to ask a dumb question.

Now, as the intern, you are the work horse of the team. Your job is to get **** done. It is now your sacred duty and privilege to bug your uppers to get stuff done as fast and safely as possible. When it comes to getting stuff done, you can now be the most vocal member of the team. There was a saying in med school, "never ask what you can look up yourself." Now, it's "always ask if it will get it done safer and faster." Don't read the whole uptodate article. Just skim the summary, what the ddx is, the w/u, and the plan.

Why abx X kills bug Y is immaterial. Now it's just, "What abx X will I Rx for bug Y?"

Change your thinking to know that you are a note monkey managing a pager.

 

[Crayola227]

The pharmacists are now your best friend, too. Get good at using your head and shoulder to hold a phone to your ear while your hands are on the computer.

 

[ratherbefishing]

I am really glad there are other people going through the same thing. Most highly efficient organizations do not train their people like this.

 

[danvasta]

This maybe a ******ed question but when you guys do H and Ps for like a million patients and it's all on the EMR, do you print out each and every one of em for rounds (or at least the rough copy with PMH, meds. Labs etc ). As a med student we didn't have as many patients so it was easy to do this. But as an intern , my pockets are just full. How do residents usually manage this ?

 

[Doctor4Life1769]

This maybe a ******ed question but when you guys do H and Ps for like a million patients and it's all on the EMR, do you print out each and every one of em for rounds (or at least the rough copy with PMH, meds. Labs etc ). As a med student we didn't have as many patients so it was easy to do this. But as an intern , my pockets are just full. How do residents usually manage this ?

Most of the interns seem to do this. that, or invest in an ipad/mini and log into the hosp EMR and use that as a guide to read off of for specifics...

 

[Crayola227]

This maybe a ******ed question but when you guys do H and Ps for like a million patients and it's all on the EMR, do you print out each and every one of em for rounds (or at least the rough copy with PMH, meds. Labs etc ). As a med student we didn't have as many patients so it was easy to do this. But as an intern , my pockets are just full. How do residents usually manage this ?

Nothing that isn't something you should know from med school is a dumb question from an intern in my view, not because that's exactly true but because you have plenty of haters already in your life (they're called all of the staff at your hospital including the janitor sometimes, thank you Scrubs), so I figure I can offer some support. We shouldn't have to feel bad about a lot of questions we ask, it's the shaming culture of medicine and our own sense of perfectionism that makes us feel we have to apologize for asking the best way to organize papers from people with more experience. Of course you're wondering that.

Yeah, 4Life is right.

My windows tablet's battery wasn't great, and the hospital wifi wasn't great, and EHR was slow, I couldn't always read my stuff off a computer (someone was on it) so paper it is!!

For some poeople the ipad or whatever device is feasible if you can manage to carry it, keep it charged, and access your EHR quickly and efficiently. The attending doesn't want to stand there tapping his toe even if it's for 2 secs or 2 toe taps to pull it up. We've all seen the eye rolls as the intern shuffles through the physical notes he's got for the census, but since they have visual confirmation of how overwhelmed you are but that indeed it is at your fingertips, there is a little more tolerance of the time it takes you to put your hands on a note than the same amount of time on the device, anytime you are using something handheld it seems like there's a question of what you're doing, and it also questions whether you had whatever it is before rounds or not. There's less patience for device lagtime I think because I think it's more amusing time filler (although annoying) to watch someone shuffle papers like a bad vaudeville skit than to ever watch someone handle a handheld electronic device. So only skip paper and use a tablet it if makes you faster/better than using paper to justify you using it on rounds.

I don't know enough about your system to make a better suggestion than the ruthless and possibly avoidable slaughter of trees in the name of intern training. Interns will try to print stuff with smaller print, more pages to a side, or will have written down what they need to present the H&P aside from their computerized note.

If you use the system where your printed notes are folded lengthwise for each patient, I organize that by using a highlighter to make the room number/name easier to see at a glance in the same location at the top of each folded sheet, then organize the sheets by floor and room number, ie order the patients will most likely to be seen. This way by quick glance and knowledge of how they are ordered, I can more quickly get out the right sheet. That stack goes in one hip pocket of my white coat. The H&Ps I fold lengthwise and keep in the opposite hip pocket, similarly organized.

Or I will carry all unpresented/unrounded on patients in one hip pocket, again with some kind of organization, like if we see all new admits first without respect to other old patients, I have those on top and the olds toward the back of the deck, and once they are talked about move them to the other hip pocket so I'm not tripping over papers of patients we've already talked about to get to the ones we haven't. So I use a system of either putting rounded-on patients at the back of the deck (stack) or into another pocket, keeping the ones we haven't seen either at top of the deck or in the opposite pocket. It depends on various factors which system is better on a given day or rotation, but basically I'm describing a stack and coat pocket based filing system, which can be organized by geography in hospital or order to be seen, or type of note, and a "discard" pile (not discarded but you don't need to shuffle through them again while you're rounding).

You could have one pocket HPs to discuss, and the other pocket progress notes, and use your breast pocket as your "done" pile to get them out of the way when you're done presenting.

I have a master to-do list of the census with all the patient names and a space next to their name to put to-do checkboxes. Most of those to-dos are ones that aren't necessarily to-dos just for that day, but more long-running things to keep track of. There's some hand-juggling to be working through your stack of presentations to read and keep this list handy to jot down to-dos as they come up on rounds. If that's too much, you can write directly on each note you're reading off of to present, with tasks that come up as you chat written with checkboxes next them.
After rounds you can complete those orders, add that stuff to your progress notes in your A/P, and the things that are still left to do for the patient's stay or the next day added to the master to-do list.
Obviously as people are dc'd and admitted your census list will change daily, so you may need to daily transfer yesterday's master to-do stuff to the new list in the am, but it doesn't take much time to do that and it keeps you reviewing the to-dos in the am on to that day's list, which you go through again in the afternoon as I've described. So you're running your own to do list on your census in the am and after rounds consistently. This is a good system especially if you're a one senior and one intern team, as it helps you figure out what to dos between the two of you were completed by one or the other, and what to-dos from the attending during rounds you may or may not have heard (even if your senior is throwing in orders while you're talking on rounds, things get left out) or may or may not have been put in, and as the lone intern on the senior's day off you have your work cut out for you. If someone is taking over your census, you are bequeathing them a nice to do list.

You only see interns struggling with so much paper compared to the residents because your jobs are different. I could explain the intricacies of why the intern knows nothing with all the papers, and the resident seems to know everything asked without all the papers, but I won't

The above may not apply to you, but they're ideas

 

[anaesthetic]

.

 

[Promethean]

This is a fantastic thread filled with great advice. I won't need it for a few years, but I'm going to keep it in mind for when the time comes. Hopefully, it will have acquired pages more awesome by then.

Just remember... every single attending, every single resident you meet... they had to do this, too. I was a nurse long enough to watch people that I met as med students become interns, become residents, fellows, and eventually attendings. I witnessed the maturing of several fine physicians through that whole life cycle. They all started out shaky, uncertain, overwhelmed--making plenty of mistakes and learning from them. When it comes my time to feel so out of my depth, I will have the comfort of having seen others go through it, too. I hope I can share a little of that reassurance with others who need it.

As for thoughts of self-harm... black humor is a defense mechanism, I get that. But if anyone is seriously feeling like that, please get help. We lose too many physicians to suicide... the equivalent of an entire medical school class each year in the US. You aren't alone, you do deserve help, and there are people who want to give it to you. Reach out. PM me, call a hotline, call Dr. Wible, somebody. You are irreplaceable.

 

[Crayola227]

This is a fantastic thread filled with great advice. I won't need it for a few years, but I'm going to keep it in mind for when the time comes. Hopefully, it will have acquired pages more awesome by then.

Just remember... every single attending, every single resident you meet... they had to do this, too. I was a nurse long enough to watch people that I met as med students become interns, become residents, fellows, and eventually attendings. I witnessed the maturing of several fine physicians through that whole life cycle. They all started out shaky, uncertain, overwhelmed--making plenty of mistakes and learning from them. When it comes my time to feel so out of my depth, I will have the comfort of having seen others go through it, too. I hope I can share a little of that reassurance with others who need it.

As for thoughts of self-harm... black humor is a defense mechanism, I get that. But if anyone is seriously feeling like that, please get help. We lose too many physicians to suicide... the equivalent of an entire medical school class each year in the US. You aren't alone, you do deserve help, and there are people who want to give it to you. Reach out. PM me, call a hotline, call Dr. Wible, somebody. You are irreplaceable.

This is a fantastic thread filled with great advice. I won't need it for a few years, but I'm going to keep it in mind for when the time comes. Hopefully, it will have acquired pages more awesome by then.

Just remember... every single attending, every single resident you meet... they had to do this, too. I was a nurse long enough to watch people that I met as med students become interns, become residents, fellows, and eventually attendings. I witnessed the maturing of several fine physicians through that whole life cycle. They all started out shaky, uncertain, overwhelmed--making plenty of mistakes and learning from them. When it comes my time to feel so out of my depth, I will have the comfort of having seen others go through it, too. I hope I can share a little of that reassurance with others who need it.

As for thoughts of self-harm... black humor is a defense mechanism, I get that. But if anyone is seriously feeling like that, please get help. We lose too many physicians to suicide... the equivalent of an entire medical school class each year in the US. You aren't alone, you do deserve help, and there are people who want to give it to you. Reach out. PM me, call a hotline, call Dr. Wible, somebody. You are irreplaceable.

Thanks for your thoughts. Feel free to cut and reproduce my advice.

Dr. Wible is awesome.

Sorry for the black humor. If you're in danger, look at some of my other threads, one called "resident made suicide joke" or something for how to get help without making things harder in medicine. There's one on chronic pain I wrote too.

DON'T push yourself to the ledge if you get what I mean. Just that things get better and even if you feel like a burden to the healthcare team, YOU REALLY ARE VALUABLE to medicine and to your team. Every bit of work you do helps the program. Don't forget that.

 

[danvasta]

Just to update you guys as the OP, it's getting better for me too. The learning curve is steep that's for damn sure, I'm seeing 7-8 patients now and I'm exponentially better. I know exactly what to look for which makes me more efficient, and if I don't know this is what saved my sanity... It's OK to ask, it's OK not to know stuff during rounds you are in training and you know what ? You will know the next time! THIS is your time to learn and make mistakes and it's only going to make you smarter. I do feel like I know 10 times more than I ever did but I've only scratched the surface. And you know what?! I love it because I'm growing!