The Home Stretch

I am 10 shifts away from the end of residency. Finally, I feel like things are coming together. Well, on some shifts I do. Other shifts, like today, make me feel like I'm an incompetent idiot. No difficult patients, no mismanagement, no problems... but a combination of little things that manage to crush any bud of confidence that might have been taking seed in my rookie brain. 

Here's a hint at how my shift went. First I started off seeing a teen with MSK pain. He had injured himself, kept playing sports, and didn't understand why it still hurt 2 months later. Gah. I re-x-rayed him to make sure that his injury hadn't displaced, and sent him out with a referral to the sports medicine clinic. Then I moved on to a traumatic finger amputation. It required a pretty extensive repair of several fingers and took me over an hour once the x-rays were done and the blocks put in (to knock out the feeling to the affected fingers). In the meantime I was working up a possibly biliary colic and an elderly gentleman with syncope. I followed that up with a therapeutic paracentesis, a suicidal teen and a pair of lower GI bleeds. I wrote admit orders (yes, we still do that at our hospital) consulted specialists and arranged admissions. And I did it all with nearly no help. I ran each case by my preceptor before discharge/consultation/admission, but otherwise barely saw him over the course of my shift.

In spite of this, my end-of-shift evaluation was mediocre at best. Among the comments:

• When I was presenting my biliary colic case to him, I accidentally said 'cholecystitis' when I meant 'cholelithiasis'. So apparently, that means that I need to review my diagnosis and management of gall bladder disorders. Regardless of the fact that based on everything else I said I clearly just misspoke and didn't actually think that a woman with a relatively benign abdomen, no fever, no white count, normal abdo bloodwork and no ultrasound findings more compelling than sludge in the gall bladder actually had cholecystitis. But apparently that one brain fart means I'm an idiot. 
• When I asked his opinion on anesthesia for my patient with the mangled hand I asked him if he thought I should do individual finger blocks or simply block the whole hand. On my evaluation he wrote that he thinks that I need to evaluate my anatomy of the hand if I think that a hand block is necessary for finger repairs. For the record, if anyone ever asks me if I want three separate finger blocks or a hand block, I'll take the hand block. But apparently, that question also attests to my incompetence.
• In a 14-year-old with melena stool, I neglected to ask the patient about binge drinking. And when the surgeon asked me about his alcohol intake, my response was "he's only 14!". When I asked him, he did indeed binge drink every weekend. So I looked bad. And naive. Oops.
• At the end of it all when I felt like I'd spent the entire shift being run off my ass, I realized that I had only seen about 1.5 patients per hour. My goal is currently 2-3. Sigh.

It really doesn't take much to knock the wind out of my sails. No matter how the shift went, I can't shake the feeling of incompetence. I feel like a complete impostor, and feel like if people only knew how little I actually knew I'd have my medical license pulled. Even when the shift goes beautifully, I have an irrational paranoia that the staff in my department all know that I had initially expressed interest in staying there after completing residency and was ignored. Like they're taking about me during departmental meetings and laughing that I actually thought I was good enough to work there. See? I told you I was losing my mind.

Not passing the exam really didn't help. It's not like I can justify things by saying to myself "well, the college thinks I'm competent enough in emergency medicine to practice independently"... clearly, they don't. And now I really regret writing the exam when I did. I would have been in a much better place mentally if I had just deferred until I was finished residency. I don't feel like I've gained anything by sitting it once already, and right now it's serving as confirmation of my deepest fears of inadequacy. 

This just sucks.