Terrible clinician, adequate test-taker. How can I prepare for residency?

[nebuchadnezzarII]

I’m a M4 with average STEP scores (230s, 240s) but TERRIBLE clinical skills. I don’t know what it is, but on the floors, something just doesn’t click and I can’t remember a lot of stuff, and my performance is just really bad. I’ve also forgotten a lot of medicine over 4th year since I’ve been doing electives/had time off.

Luckily, I only have to survive 4 months of internal medicine for my residency. (I’m doing psych).

What can I do in the next 90 days to be a passable internal medicine intern? I don’t want to hurt anyone and I don’t want to feel stupid. It’s very humiliating being on the floors for me - I get overwhelmed easily and common sense tends to disappear.

---

Members don't see this ad.

 

[rokshana]

I’m a M4 with average STEP scores (230s, 240s) but TERRIBLE clinical skills. I don’t know what it is, but on the floors, something just doesn’t click and I can’t remember a lot of stuff, and my performance is just really bad. I’ve also forgotten a lot of medicine over 4th year since I’ve been doing electives/had time off.

Luckily, I only have to survive 4 months of internal medicine for my residency. (I’m doing psych).

What can I do in the next 90 days to be a passable internal medicine intern? I don’t want to hurt anyone and I don’t want to feel stupid. It’s very humiliating being on the floors for me - I get overwhelmed easily and common sense tends to disappear.

And remembering stuff and having things click aren’t required in psych?

Sounds like it’s more of an issue of not liking something.

Make a list of the things you need to do, practice your presentations, and keep your seniors in the loop .

 

[GoSpursGo]

Seriously, this is a case where showing that you give a crap goes a long way. Nobody likes the jerk who clearly is just counting down the days until he gets off service and is trying to get by with the minimum effort, but if you show you’re trying to learn you’ll do fine.

Recognize that since you have the smallest fund of knowledge for IM on the team, you’re going to take longer prepping your patients in the morning. Be the first one there, and ask your seniors for help when you need it. They know you’re not in IM, and you’re likely to need more help than most.

 

[Raryn]

I’m a M4 with average STEP scores (230s, 240s) but TERRIBLE clinical skills. I don’t know what it is, but on the floors, something just doesn’t click and I can’t remember a lot of stuff, and my performance is just really bad. I’ve also forgotten a lot of medicine over 4th year since I’ve been doing electives/had time off.

Luckily, I only have to survive 4 months of internal medicine for my residency. (I’m doing psych).

What can I do in the next 90 days to be a passable internal medicine intern? I don’t want to hurt anyone and I don’t want to feel stupid. It’s very humiliating being on the floors for me - I get overwhelmed easily and common sense tends to disappear.

As someone who worked with plenty of Psych interns during his IM residency, this is not uncommon.

Your advice is the same as for anyone else:

1) Show up on time - which means being early for signout

2) If there's ever anything you're unsure of, ask your senior. I mean, if it's something simple, look it up- but your seniors are there to support you.

3) Never lie. If someone asks you a question about something you did or didn't do, tell the truth

No one expects you to be able to manage anything - anything at all - your first day. But if you do the above, can write a passable note, and make sure the chain above you is always well informed of what you're doing? You'll get through the 4 months of medicine just fine. No one expects the Psych interns to be Osler, just to give it good effort.

 

[nebuchadnezzarII]

Seriously, this is a case where showing that you give a crap goes a long way. Nobody likes the jerk who clearly is just counting down the days until he gets off service and is trying to get by with the minimum effort, but if you show you’re trying to learn you’ll do fine.

Recognize that since you have the smallest fund of knowledge for IM on the team, you’re going to take longer prepping your patients in the morning. Be the first one there, and ask your seniors for help when you need it. They know you’re not in IM, and you’re likely to need more help than most.

I’m glad there is some mercy!

As someone who worked with plenty of Psych interns during his IM residency, this is not uncommon.

Your advice is the same as for anyone else:

1) Show up on time - which means being early for signout

2) If there's ever anything you're unsure of, ask your senior. I mean, if it's something simple, look it up- but your seniors are there to support you.

3) Never lie. If someone asks you a question about something you did or didn't do, tell the truth

No one expects you to be able to manage anything - anything at all - your first day. But if you do the above, can write a passable note, and make sure the chain above you is always well informed of what you're doing? You'll get through the 4 months of medicine just fine. No one expects the Psych interns to be Osler, just to give it good effort.

Thanks, will do just that. I’d like to think I’m not a malignant worker; I’m just not very good clinically. But I’ll work hard. This routine seems helpful.

 

[Mass Effect]

I’m a M4 with average STEP scores (230s, 240s) but TERRIBLE clinical skills. I don’t know what it is, but on the floors, something just doesn’t click and I can’t remember a lot of stuff, and my performance is just really bad. I’ve also forgotten a lot of medicine over 4th year since I’ve been doing electives/had time off.

Luckily, I only have to survive 4 months of internal medicine for my residency. (I’m doing psych).

What can I do in the next 90 days to be a passable internal medicine intern? I don’t want to hurt anyone and I don’t want to feel stupid. It’s very humiliating being on the floors for me - I get overwhelmed easily and common sense tends to disappear.

I was you. Believe me you'll be ok. It'll be hard, very hard, but your senior and attending will understand that you're psych and likely didn't do a lot of medicine in med school. Get there early, work hard, do all your notes, read up on your patients, treat everyone well (especially nurses who will have your back and often page you and say "so and so has ____ ...usually when this happens we do xyz") and you'll be okay.

 

[nebuchadnezzarII]

I was you. Believe me you'll be ok. It'll be hard, very hard, but your senior and attending will understand that you're psych and likely didn't do a lot of medicine in med school. Get there early, work hard, do all your notes, read up on your patients, treat everyone well (especially nurses who will have your back and often page you and say "so and so has ____ ...usually when this happens we do xyz") and you'll be okay.

Thanks man. Means a lot getting some advice. It's a scary time (especially for the baseline nervous!).

 

[20gauge]

I’m a nurse. My experience is obviously different as I’m not a doctor, however I had the same issues when I started my clinical rotations.

I couldn’t figure out what I was supposed to be doing, let alone how I was supposed to be doing it.

It was painfully obvious that I was uncomfortable and couldn’t figure out what to do with my hands. All common sense went out the window.

I remember my preceptor asking me to get a box of gloves from the clean utility room. I stood in the room for ten minutes staring at what appeared to be materials that had something to do with healthcare, but god forbid if I could figure it out. It was not my proudest moment.

I found that school taught me the technical information I needed to know, but it failed to help me understand nursing from a WORFLOW perspective. That is what stumped me.

To address this issue I sought out resources that focused on the ‘bigger picture’, as opposed to the nuts-and-bolts knowledge I’d acquired in school. It helped put the pieces together.

Good luck!

 

[FrustratedFamDoc]

If you approach a patient as a nebulous of facts, then you'll quickly get confused and overwhelmed. Present patients as a story and things fit in to place a lot better. You don't have to try to blow away your attending with your ability to remember every small detail.

Good: "Mr Smith is on day 4 of admission for DKA. Type 1 diabetic who presented to the ER with 12 hours of N/V, etc. Initially placed on glucomander protocol but was weaned yesterday. He says that he's feeling much better. His labs are improving and he feels like he can go home today." You don't need to remember off the top of your head all of his labs, home meds (diabetes meds yes), social habits, etc.

Bad: Mr Smith's potassium dropped to 3.3 last night and he had an episode of diarrhea that he thinks was due to the nasty hospital food. We did a CBC and his white count looked good. I think the night team may have also done an EKG for some reason.

One shows that you have a good grasp on why the patient is there in the first place and what has been done, the other just looks like you skimmed the AMs labs in an effort to hurry up and move on to the next patient. '

Show up early, have a good attitude, and be teachable and you'll do better than most.

 

[Raryn]

If you approach a patient as a nebulous of facts, then you'll quickly get confused and overwhelmed. Present patients as a story and things fit in to place a lot better. You don't have to try to blow away your attending with your ability to remember every small detail.

Good: "Mr Smith is on day 4 of admission for DKA. Type 1 diabetic who presented to the ER with 12 hours of N/V, etc. Initially placed on glucomander protocol but was weaned yesterday. He says that he's feeling much better. His labs are improving and he feels like he can go home today." You don't need to remember off the top of your head all of his labs, home meds (diabetes meds yes), social habits, etc.

For a brand new intern, this is an awful presentation. "His lab are improving and he can go home today" is a fine statement if you are a known quantity and I can trust your judgement as to understanding his labs and what improvements explicitly need to be done before the patient can go home - but if you aren't a known quantity, you could be far off the mark - and without an appropriate presentation, there's no way to know. You might be able to get away with this sort of presentation in the latter half of the year - never in the beginning.

Better: "Mr. Smith is our 45 year old man who presented for type 1 DM with ketoacidosis. He was admitted three days ago, was transitioned from IV to subq insulin yesterday. Currently feeling well without complaints and desires to go home. His vital signs are appropriate with a heart rate in the 90s, blood pressures in the normotensive range, and he remains afebrile. Exam is benign. His chem panel shows that he remains mildly hypokalemic - 3.3 - and his bicarb has improved to 18, otherwise unremarkable. CBC is within normal limits and his last pH on a VBG was 7.34. His blood sugars over the last day have varied from 150 to 210, and he has required 12 units of correctional insulin in addition to his scheduled basal/bolus. In short, this is our 45 year old diabetic who has been treated for DKA, now on subq insulin. For his first problem of diabetes, I think we should increase his insulin doses to XYZ. He is eating well. For his hypokalemia, I have already ordered N meq of oral KCl. For his comorbid HTN, I have continued his home medications. I think we can discontinue his IV fluids at this time. For discharge planning, I think we could repeat a chemistry panel this afternoon and consider discharge if the potassium is better and he remains stable."

That's a presentation that I would expect of an intern - and everything prior to the plan is the bare minimum. Many attendings may require more detail than that - but if it's truly Mr Smiths day 4 on service, that should be fine. Personally I'd want even more detail regarding the blood sugars, but that's me. For the plan, it's important to go over it with your senior prior to presenting to the attending - at least at the beginning of the year. But you cannot start skipping the objective data. Not in July.

 

[nebuchadnezzarII]

I’m a nurse. My experience is obviously different as I’m not a doctor, however I had the same issues as you when I started my clinical rotations.

I couldn’t figure out what I was supposed to be doing, let alone how I was supposed to be doing it.

It was painfully obvious that I was uncomfortable and couldn’t figure out what to do with my hands. All common sense went out the window.

I remember my preceptor asking me to get a box of gloves from the clean utility room. I stood in the room for ten minutes staring at what appeared to be materials that had something to do with healthcare, but god forbid if I could figure it out. It was not my proudest moment.

I found that school taught me the technical information I needed to know, but it failed to help me understand nursing from a WORFLOW perspective. That is what stumped me.

To address this issue I sought out resources that focused on the ‘bigger picture’, as opposed to the nuts-and-bolts knowledge I’d acquired in school. It helped put the pieces together.

Good luck!

Yes!! This is me! Thanks so much for your input. Can you give me some examples of big-picture resources you used?

 

[GoSpursGo]

For a brand new intern, this is an awful presentation. "His lab are improving and he can go home today" is a fine statement if you are a known quantity and I can trust your judgement as to understanding his labs and what improvements explicitly need to be done before the patient can go home - but if you aren't a known quantity, you could be far off the mark - and without an appropriate presentation, there's no way to know. You might be able to get away with this sort of presentation in the latter half of the year - never in the beginning.

Better: "Mr. Smith is our 45 year old man who presented for type 1 DM with ketoacidosis. He was admitted three days ago, was transitioned from IV to subq insulin yesterday. Currently feeling well without complaints and desires to go home. His vital signs are appropriate with a heart rate in the 90s, blood pressures in the normotensive range, and he remains afebrile. Exam is benign. His chem panel shows that he remains mildly hypokalemic - 3.3 - and his bicarb has improved to 18, otherwise unremarkable. CBC is within normal limits and his last pH on a VBG was 7.34. His blood sugars over the last day have varied from 150 to 210, and he has required 12 units of correctional insulin in addition to his scheduled basal/bolus. In short, this is our 45 year old diabetic who has been treated for DKA, now on subq insulin. For his first problem of diabetes, I think we should increase his insulin doses to XYZ. He is eating well. For his hypokalemia, I have already ordered N meq of oral KCl. For his comorbid HTN, I have continued his home medications. I think we can discontinue his IV fluids at this time. For discharge planning, I think we could repeat a chemistry panel this afternoon and consider discharge if the potassium is better and he remains stable."

That's a presentation that I would expect of an intern - and everything prior to the plan is the bare minimum. Many attendings may require more detail than that - but if it's truly Mr Smiths day 4 on service, that should be fine. Personally I'd want even more detail regarding the blood sugars, but that's me. For the plan, it's important to go over it with your senior prior to presenting to the attending - at least at the beginning of the year. But you cannot start skipping the objective data. Not in July.

Just want to +1 this. While keeping an over-arching one-liner for each of your patients is helpful for how you frame your patients in your mind and give your presentation, you've got to remember that your attending (and maybe your senior) haven't gone through every vital sign or lab for the patient yet when they show up for rounds. They depend on you to know and present that granular level of detail so that when you make your assessment and propose a plan, they'll be able to determine whether or not you're on point.

There's one service during our fellowship where we're essentially working as a resident (no residents on the team, so we have to see the patients and present on rounds). Even as fellows, we all got dinged by the attendings for not giving enough details early on in our presentations before they got to trust us. So just like an MS3, don't be afraid to bore your team to death with details early on. It's going to be inefficient, but let your senior and attending tell you when they're comfortable with you starting to short-cut your presentation.

 

[20gauge]

Yes!! This is me! Thanks so much for your input. Can you give me some examples of big-picture resources you used?

I'm glad you could identify with me. You're not alone!

I remember taking someone's vital signs during clinical and the O2 finger probe wasn't picking up a reading on my patient, so I put the probe on my finger to check if it was working. Oh, it was working all right - my heart rate clocked in at a cool 132 bpm. I could feel my heart beating through my chest. It's no wonder I couldn't think clearly.

The good news is: I turned out to be a really good nurse. I found a way to "chunk" the seemingly random data I learned in school into meaningful information I could apply to my patients... once I understood the workflow.

I will send you a PM.

 

[DeucesHigh3]

Just want to +1 this. While keeping an over-arching one-liner for each of your patients is helpful for how you frame your patients in your mind and give your presentation, you've got to remember that your attending (and maybe your senior) haven't gone through every vital sign or lab for the patient yet when they show up for rounds. They depend on you to know and present that granular level of detail so that when you make your assessment and propose a plan, they'll be able to determine whether or not you're on point.

There's one service during our fellowship where we're essentially working as a resident (no residents on the team, so we have to see the patients and present on rounds). Even as fellows, we all got dinged by the attendings for not giving enough details early on in our presentations before they got to trust us. So just like an MS3, don't be afraid to bore your team to death with details early on. It's going to be inefficient, but let your senior and attending tell you when they're comfortable with you starting to short-cut your presentation.

And I would add -- even if they *don't* request that granular level of detail on each patient, you should definitely have it at hand. Meaning literally at hand, written with ink on paper, for immediate reference. Not 10 seconds away as you bring it up on the EMR on your device or the team's COW. If there's a critical lab value in flux that has been re-checked since you pre-rounded, the senior will probably be pulling it up in realtime anyway, but the paper rounding sheet proves that you actually did do the work of gathering all the data that morning.

 

[J ROD]

I did very well on my medicine rotations as a psych intern. How? I showed up early, replaced electrolytes in am and knew what was going on major issues with each pt. Also on medicine you need to have basic knowledge of each patient on the team bc you rotate days off and have to pick each other’s patients up. As mentioned depend on seniors for guidance but don’t be a burden. You still have to maintain a basic level of doctoring. Appear to be interested that counts a lot. Another thing I did was take medicine patients on my team that were social disposition problems and work with social work for placement. Medicine folks hate it and as psych we deal with it all the time. They appreciate it as they want more complex medicine patients and I sure as hell didn’t lol. Moreover I got tons of love for moving those rocks off the team. Made me look much better than I actually was.

 

[nebuchadnezzarII]

Slightly unrelated but does anyone know a good reference/handbook for starting intern year? Like with practical advice (not with advice on how to get along with people like the intern handbook).

I feel like I have a pretty good understanding of pathophysiology and management, but the understanding is still vague and theoretical. Not practical.

 

[siliso]

Did you get terrible clinical evals? Did you fail CS? Agree with all above advice but would add to consider whether you may be suffering an anxiety disorder that impacts your performance. Treatment helps.
Also I think the onlinemeded intern guide is plenty practical with a lot of fundamental approach to common problems as well as the interpersonal and time management advice.

 

[90sportsfan]

This is incredibly helpful information in this thread (I learn so much on this forum being a med student), as I am a rising M3, scared to death to begin "actual medicine" in the real world, rather than the didactic world we've been in the last 2 years.

As the poster above mentioned, I'm also wondering if OP, you are having anxiety issues when it comes to actually working with real patients (in a real-world setting). It's something I've heard lots of med students worry about (we can do fine on all of the tests, but how will we fare in the "real world?").

I haven't experienced it yet, but I'm guessing there is a variable learning curve from didactic medical school knowledge to real-world clinical knowledge and performance. Some likely pick up on it quickly and for some it probably takes a long time, with average students somewhere in the middle. It could just be that it is taking the OP a little longer than average to pick up on the clinical stuff, which may be okay. But if you are at the end of M4 and really feel like you haven't seen any improvement at all, I'm wonder (like the poster above) if some sort of anxiety related to patients or the clinical environment may be impacting your performance?

I know once I start rotations I will be a nervous wreck and will probably forget everything I learned didactically, but I hope that as I progress through M3/M4, I will get more and more noticeably comfortable and confident.