Worried my clinical learning during M1/M2 will cause difficulty moving forward

Fried Plantaris

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The whole learn the OSCE checklist the day before and move on approach I took, while focusing on crushing anki/uworld during my preclinicals is making me worry I'll have difficulties adjusting to clinic.

My concern is when I am interviewing patients, I am constantly trying to focus on what questions to ask next, and not giving enough attention to remembering the patient's story. My memory for stuff like this is generally poor. When I was a server years ago, I always had to write down orders cause I would forget, and sometimes I had to even ask them to clarify because my brain would zone out. When I've tried writing the highlights of a patient's story down, it creates somewhat of an awkward pause in the flow. Some of the better history takers I've seen take histories as part of a natural conversation, one that is smooth and efficient. My histories are piecemealed together already and writing just makes it more noticeable. On top of that the notes I've seen from residents are super detailed and touch on aspects of the conversation that I am unable to explain in as many words as they do. I've been trained by prior jobs to keep my written communication as succinctly as possible and naturally that often means I am inclined to not delve into finer detail.

I'm a smart student by the books, but transferring that knowledge into clinical applications has proven difficult. I usually have to stop and think about the problem rather than knowing the answer off the top of my head. This is not ideal in a fast-paced floor or clinic. My differentials are lacking because of this and it is affecting my confidence in taking on more patients. Every morning is a rush to get the progress notes written up before rounds. What should I do? I'm lacking in time to address each concern from above in full and that's stressing me out, knowing I have areas that are suboptimal.

Sincerely,
-Concerned M2 moving forward
 

Redpancreas

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The whole learn the OSCE checklist the day before and move on approach I took, while focusing on crushing anki/uworld during my preclinicals is making me worry I'll have difficulties adjusting to clinic.

My concern is when I am interviewing patients, I am constantly trying to focus on what questions to ask next, and not giving enough attention to remembering the patient's story. My memory for stuff like this is generally poor. When I was a server years ago, I always had to write down orders cause I would forget, and sometimes I had to even ask them to clarify because my brain would zone out. When I've tried writing the highlights of a patient's story down, it creates somewhat of an awkward pause in the flow. Some of the better history takers I've seen take histories as part of a natural conversation, one that is smooth and efficient. My histories are piecemealed together already and writing just makes it more noticeable. On top of that the notes I've seen from residents are super detailed and touch on aspects of the conversation that I am unable to explain in as many words as they do. I've been trained by prior jobs to keep my written communication as succinctly as possible and naturally that often means I am inclined to not delve into finer detail.

I'm a smart student by the books, but transferring that knowledge into clinical applications has proven difficult. I usually have to stop and think about the problem rather than knowing the answer off the top of my head. This is not ideal in a fast-paced floor or clinic. My differentials are lacking because of this and it is affecting my confidence in taking on more patients. Every morning is a rush to get the progress notes written up before rounds. What should I do? I'm lacking in time to address each concern from above in full and that's stressing me out, knowing I have areas that are suboptimal.

Sincerely,
-Concerned M2 moving forward
Medical school can be difficult when there's so many people with so many different backgrounds who have different strengths you don't have. It's easy to convince yourself you don't belong. I have no way of knowing whether or not you're exaggerating this issues or whether this is a legitimate concern, but it's best to err on the side of caution and seek help to address it. I started to have similar issues to the ones you're having when we did Clinical Diagnosis class in M2. One ugly thing about medical school is that we sometimes grade without taking into the account certain people are willing to learn and improve, but are not where they need to be right now and many did not have the chance to fully develop these skills while others did.

I believe the problem you're having is a combination of situational anxiety and perhaps lack of mental organization. This can be oftentimes confused with ADHD, Anxiety Disorders, etc. Here are a few suggestions I would make:

1.) Create a foolproof systems. Doing this will take the mental anxiety of having to worry about the next step so you can focus on the conversation at hand.

A.) Create mnemonic checklists in your head (like the HPI one you were taught) but for everything else too. Create them for the order you're supposed to go in (HPI, ROS, Vitals, Ins/Outs, Physical, Labs, Imaging, Plan-HR. VIPLIP).

B.) Memorize strings of ROS questions that roll off the tip of your tongue. For example, abdominal pain, nausea, vomiting, diarrhea can be for GI ROS.


2.) Regardless of the fact that you think you suck, you really don't. You're the product of thousands of years of evolution designed to understand the needs and empathize with other humans. When you're stressed out, you turn off these inherent traits you possess as a human and let anxiety get the better of you. Some may say you're robotic, etc. Whenever you're with a patient unless they're unstable, sit down, talk with them, do treat it like a conversation. This is the best way to get what you need from them. It may feel like it takes longer, but learn to do this with every patient. When you learn to do this, you'll find yourself losing time and getting too focused on the conversation. At that point, you need to start learning to plan your approach beforehand. (point 3).

3.) The best doctors have a great sense of anticipation. The minute you read the vital signs your mind should be churning. What does this rule in/out and what moves up and down my differential. This happens each time new information is revealed. Before each case you'll be given XYZ information and it will be your job to do the H&P and make a plan. Before you even have the potential to sit down and get distracted with the patient, have an agenda beforehand based on what you anticipate the case is going to be about. Write down only the most essential topics you want to discuss/ask beforehand so if you do get distracted during the conversation you can always refer back to that.

Doing these three things will make OSCE's a whole lot easier. Like I said before, it's a combination of strategies to organize yourself and reduce your anxiety. When you're a medical student/resident, you should never be too anxious as it's a sign you're overwhelmed. The best analogy I have is that as a marathon runner my goal was to be in a constant state of aerobic metabolism. If I went too hard for the day, I would start experiencing anaerobic metabolism like abdominal pain, dry mouth/throat, muscle cramps and when this happens, I stop and restart at a slower pace or restart the next dat. You need to learn to recognize signs for when you're overwhelmed (unable to remember what was said a minute ago) and take the necessary actions (a deep breath, etc.) to readjust to your surroundings.
 
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Fried Plantaris

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Medical school can be difficult when there's so many people with so many different backgrounds who have different strengths you don't have. It's easy to convince yourself you don't belong. I have no way of knowing whether or not you're exaggerating this issues or whether
I was trying not to exaggerate. I can get by right now fine as is, but I know there will come a time where it will catch up to me at the current trajectory. I want to start making improvements now so I can avoid missteps down the road with patients as a resident.
 
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Redpancreas

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I was trying not to exaggerate. I can get by right now fine as is, but I know there will come a time where it will catch up to me at the current trajectory. I want to start making improvements now so I can avoid missteps down the road with patients as a resident.
@Fried Plantaris This is very commendable! See above.
 
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Fried Plantaris

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@Fried Plantaris This is very commendable! See above.

Hey man, thanks for your input! Those tips include a few things I have tried before like the acronyms. It does work good, although I should look to make one more permanent moving forward. As for the others, I will try to make changes like anticipating more. I think your marathon analogy speaks well to me, I gotta strive for the aerobic side of things moving forward.

Best
 

Osteosaur

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You just need to get used to talking to patients and that is what third year is all about. It can be very intimidating at first, but you'll be surprised what you remember. I'm a very introverted person and this was a fear I had in second year as well.

As you do more OSCEs you'll commit the basic SOAP structure to memory. Its a script to get you on track if you get lost in the weeds. If you feel there is an awkward pause and you've asked everything you possibly can in the HPI you jump right to "what meds are you taking" and then do an ROS or fedtacos or whatever is relevant for the complaint.

You aren't there to socialize or have a conversation without awkward pauses. You're trying to get useful information and do a job.
 
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mrbreakfast

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Just focus on learning the basic format for now. Very formulaic, going down your list of questions to ask. When did it start, what makes it better/worse, etc.

As an M3 you'll practice this on real patients, who are sometimes actually easier to interview than the standardized patients.

As an M4 you'll work on flow and bedside manner. The entire interview should go like an open-ended conversation.

As a resident you'll work on things like getting the history quickly or doing several histories back-to-back.

It gets easier with practice.
 
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Dr G Oogle

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It’s pretty normal to forget things and be anxious as an M2. Are you not allowed to write things down during these interviews? In general as a M3 and beyond you can write stuff down so Yih don’t forget. I got so flustered during one patient interview as an M1 that I forgot to ask a bunch of stuff and had to remediate the interview. Despite of this I still manage to eek out a living as a practicing doctor. Don’t sweat these little hoops everyone has to jump through, no when else in your career will you need to do this specific type of activity
 
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Use mnemonics and templates whenever you can. If you are writing notes on paper, create an H&P form for yourself; if you are using an electronic device, make a template. If you follow the same format every time, it will soon become comfortable and natural.
 
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Matthew9Thirtyfive

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Also OSCEs and the real world aren’t really the same. In an OSCE, they want you to do things a certain way, you usually aren’t allowed templates, you can’t chart dive first, etc. With real patients, you can literally jump into their chart for a couple minutes and see what they are there for, look briefly at their history and meds, and then jot down some important questions you need to ask them so you don’t forget. You can even look it up on uptodate real quick if you need to.

And when you’re interviewing, absolutely write it down. I do that for every patient. I just tell the patient I’m going to jot some notes down, and I just use short hand so it doesn’t take a long time to write things. I also don’t write as they’re talking. I’ll only write stuff down at like natural breaks or if they start talking for more than 15 or 20 seconds.

Additionally, if you remember something after you leave the room but before you go present, you just go back and ask. It’s no big deal and the patient won’t think it’s weird unless you act weird about it.

Third year is where you get practice doing this stuff.
 
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