The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Sunday, November 23, 2008

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.


Anonymous Anonymous said...

hello couz,

I'm here to cheer you on that despite what you have posted I still think you are and will continue to be a great doctor. I am sure they are somethings that you could improve upon which I am sure you would :-)

Definitely look forward to the positive, which is 10 shifts left. So I'm cheering you on once more!!! GO COUZ!!!!!


9:59 PM

Blogger Beach Bum said...

Success consists of going from failure to failure without loss of enthusiasm.

Winston Churchill

6:16 AM

Anonymous Anonymous said...

Let me speak for a minute from a preceptor side. We have to evaluate you guys on *something*. Near the very end of their residencies, I can get pretty tough on people too--but it's not meant to knock their confidence, it's meant to point out the nitty gritty stuff that in a few short weeks, you will never be told again. Once you're in independent practice, you will NEVER receive feedback from anyone of this nature. So, I can sympathize slightly with your preceptor.

Or, s/he's just a total jerk.

Regardless, if you were my resident, you would also have received this boost at the end: "The main thing about this shift is that You Did It. You saw them, you worked them up appropriately, and if I hadn't been here saying a thing to you, you would have Totally Dealt with all of these patients. So what if I prefer finger blocks & you prefer a hand block? So what if you miss one detail on a history? If I hadn't been here, and you had still done those things, everyone would still have been treated perfectly, brilliantly appropriately. You still would have acutely managed the teen & got him a scope. And you would have beautifully repaired that hand. And you know what? He might have even been more comfortable. Imagine that--you might have a better idea than me!".

At this stage, that's what you're there for. You are gleaning your final bits of whatever you can glean. But your foundation is in place and you are going to be safe and competent--and even brilliant. Trust me.

4:15 PM

Anonymous Anonymous said...

PS. Oh, and you'll speed up once you're not frigging doing all that presenting & justifying yourself to a preceptor! seriously! Don't you find that takes forever?!

4:17 PM

Blogger Couz said...

Thanks to all for their encouragement. But thanks especially to anonymous preceptor. That actually made me feel a lot better.

6:09 PM

Blogger Liana said...

anonymous preceptor is right. You shouldn't feel too bad. Okay, #1 brain fart. #2 I probably would have done a Bier block, and besides, you're a resident so you're supposed to ask questions and a preceptor who puts you down for that needs a reality check. If I were back in residency I would totally ask a million and one questions. #3 So you missed one point on history.

So that's the best he could come up with?

7:45 PM

Blogger Nikki said...

I sympathize, I really do. I feel like a big fake most of the time, and I can hardly believe they're going to let me loose on the world in less than a year. I always wanted to do "full service" rural practice but the idea of doing ER and OB independently next summer scares the crap out of me.

It looks like you only made one actual mistake (leaving out binge drinking in your questions), and a relatively minor one at that, among all those criticisms from your preceptor. I'd say that kind of overzealous critique is doing nothing for your confidence.

I had to sit my preceptor down a little while back and tell him I didn't want to hear the little criticisms. I realized that when he nitpicked something minor that I already knew I'd goofed, he just killed any confidence I had about what I had done right. He thought he was just offering "suggestions" and "different ideas" but to me it felt like I never actually nailed a case.

It seems strange to be asking for less feedback, but I feel like what I need now is confidence in what I do know plus the sense to look up the stuff I don't - instead of spending every day feeling like everything I do is wrong. And when I told my preceptor that, he started giving me more positive feedback, which has been really good for my confidence - and makes the negative feedback much more helpful because I have some perspective.

Thinking of you.

9:03 AM

Anonymous Anonymous said...

Just keep plugging along, Couz. RNJericho at The Nurse Resource

5:36 PM

Blogger Irishdoc said...

Almost done with residency? I envy you.

10:14 AM

Anonymous Anonymous said...

Congratulations on the impending completion of your residency. It seems that you are ready to get going in the medical profession. You should also make sure you are ready and covered as you get going into physician life to, remember to protect your income.

5:52 PM

Blogger DHS said...

I hate preceptors like this!

(FwIW, i would never do a hand block for finger injuries. they're dangerous and difficult. blocking each finger is really easy, especially for adjacent fingers.)

9:33 PM

Anonymous Dr S said...

Hey Doc - So...I hear you! And yes, three years post qualification in Cape Town, South Africa, I too feel as if the imposter police are gong to jump out from behind the equipment trolley and cuff me and take me away for pretending to know what I'm talking about!

But honestly, I think that this is an important trait o avoid developing the God complex we've all witnessed in those arrogant shitty specialists we know...

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Blogger Dr. Dan Woodard said...

I agree on the hand block. But if you can see 1.5 patients per hour with this level of trauma you are doing about the limit. Most ER doctors see far more patients than they can take care of well. Personally I have seen a lot of residency-trained emergency physicians who are stuck-up jerks who think they need to show how many patients they can see at once. They get $250 an hour and patients have to wait hours. Anyone who thinks he is going to jam all the facts you need into you be being a hardass is a fool. The most important thing to learn is that you never know everything, or even almost everything, so if you want to practice good medicine take the time to listen to each patient and ask about everything that might be relevant, and use google every chance you get. I am 60 and have been in practice 30 years. I learn something new every day.

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Anonymous Anonymous said...

I think this was a great post. It makes me realize that you are not alone and that medicine is truly a life long learning process. Residency and even a post residency fellowship doesn't mean that you know it all. Nobody knows everything and those that think they do are just plain dangerous or oblivious to it all. The key in this whole process IMHO is to understand that it is a collaborative effort and to not be worried to ask for help if you need matter who you are

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Anonymous Anonymous said...

I just found your blog and start reading a few of your posts. I am a resident in the CCFP-EM year and this post really echos how I have been feeling. I have the same irrational paranoia that the department is all discussing my inadequacy, the feeling of being completely incompetant - even after a "great" shift, the wondering of why the heck I ever chose to do this and yet couldnt see myself doing anything else. Thank you for sharing.

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Anonymous Jennifer said...

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Anonymous Anonymous said...

Hello, I know this is a really old post and you are now practicing EM somewhere as an awesome doc but I wanted to thank you for sharing. I found out last night that I failed my EM Boards yesterday night. I was completely shocked and have not quite recovered. Although I know I came out of the exam feeling like I failed, I come out of every exam that way and have not failed a single exam yet!
So for some unknown reason I googled 'failed EM board exam'.
This post made me cry (probably more likely the emotion of failing the exam). You voiced exactly how I felt just a few short months ago as I was completing residency and how I feel now. Completely incompetent to practice emergency medicine and just waiting until the carpet is pulled out from under when it's discovered by others.
It would be great to hear/read how you are doing now.
thanks for sharing.

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