Am I just not built for this specialty?

[EthylMethylMan]

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[pollyspockets]

I think you have to give yourself a little more time. I remember being terrified to be a PGY2 because one more layer of your safety net was gone. Lean on your attendings when you have questions. For every patient, think “what’s the worst thing this could be” and evaluate for that. Remember your ABCs. Run your list, including labs and imaging when you return to your computer. If you could already do all this, you wouldn’t need residency! If your anxiety follows you home, think about seeing someone.

 

[watermanMD]

Just here to say I hear you and am struggling myself. I have great, fun days but also intense or slow ones that feel numbing. I constantly question my abilities. I’m having a particularly hard time with two things, 1) staying in the EM mindset of “what’s the worst possible thing?” and 2) the CYA mentality—I’m often too conservative. I feel like we order “everything” most the time. Couldn’t a computer or midlevel do that?

Maybe I’m still too green to see that this is how it has to work. Don’t know how different it is in other shops.

With the EM job market doom/gloom, some days I wonder about going back for a second residency. Also strongly considering fellowship. Just going to keep chugging along for now.

 

[BoardingDoc]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

PGY-2 at most EM programs is where you get thrown to the wolves and start seeing a lot more critically ill patients and are suddenly expected to see a LOT more volume. If your program is like that as well, this feeling is normal. My first few months as a PGY-2 I had days where I was like "ok, so on top of the random BS patients I've got 3 patients on pressors.... I can't remember why any of them need pressors, and I'm not actually sure what room one of them is even in." This is normal and will pass. As others have said, lean on your seniors/attendings as needed but the entire point of this process is that you're going to make mistakes, you're going to learn from them, and its your senior's/attendings job to catch those mistakes before anything happens.

 

[Fox800]

PGY-2 is the worst year, bar-none. I frequently felt mega-stressed and in over my head. You'll pull through.

 

[Groove]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

It takes time to develop pattern recognition...in everything. The pathology, the cases, the management, the pt’s, the procedures, the execution, etc.. After you develop some pattern recognition, you’ll develop confidence in the cases that stems from familiarity. Everyone is anxious when they are thrown into the ocean but you’ll learn to tread water and swim soon enough. You’ll be fine.

Here’s a tip during residency. Get PEPID on your phone and discreetly reference it before presenting to your attendings. You can easily brush up on the pathology, diagnostics and management and then you’ll impress when you inevitably get pimped a few minutes later.

As for the multi-tasking, that just takes practice.

 

[WilcoWorld]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

If I wanted to characterize my internal state during the 1st 6 months of EM PGY-2, I could do it with the following single sentence:

"What the *^$# have I gotten myself into?"

 

[WilcoWorld]

As for the multi-tasking, that just takes practice.

Lot's of good advice in your post, but I'd like to edit this last piece.

Don't try to multi-task, everyone sucks at that. Learn to task-switch. That means remembering to return to what you were interrupted from after the interruption is over. This gets really hard when you start getting interruptions to your interruptions. As a young EP, I found keeping running to do lists on my patients helped a lot with this.

 

[NITRAS]

A lot fewer people talk about the jump from PGY1 to PGY2 and Resident to staff (especially at a different place). Both of these are a lot bigger than MS4 to PGY1 because everyone just assumes you know nothing as a PGY1.

I deal directly with the residents a lot and the PGY2’s can just get overwhelmed. I remember one of the other Hospitalist joke that our EM residency is a self directed residency.

Don’t worry, its a season that will get better. You really aren’t as alone as you think.

 

[EctopicFetus]

Its natural. When i started pgy2 i remember getting myself mentally prepared for every shift. Where I trained we were expected to carry to load of the dept while the interns sputtered and the seniors "ran" the dept. We were the mules. You got this.. it will get easier. Embrace the training and pain and fear to make yourself a better doc.

 

[sdles]

Completely normal.

These overwhelming moments you are currently experiencing, are paradoxically what will give you confidence when you get into sticky situations again as an attending.

When that nasty triple trauma comes in, with simultaneous undifferentiated grandma fall on Coumadin with a waiting room full of worried well....

You will think back to your training, take a deep breath, and plunge into the foray that is emergency medicine

 

[Vandalia]

I would say that it is likely not... abnormal.

The question is how did you do as a PGY-1? If you were struggling as a PGY-1, had some of the same issues, and were far behind your peers, then it might be time to start asking for advice.

If this is new onset with your start as a PGY-2, especially with everything else in the world and in medicine going crazy, I would not be too concerned.

I used to tell residents to not be concerned about how they are doing in a given year until at least the first kickoff of the college football season. That might not apply so well this year; or on the other hand, with the chaos I mentioned above, it may still be good advice.

 

[deleted859535]

If I wanted to characterize my internal state during the 1st 6 months of EM PGY-2, I could do it with the following single sentence:

"What the *^$# have I gotten myself into?"

Good. You're honest (to the OP, not you, WW).

The folks at your level of training that don't get that feeling to some degree are the ones who, to abuse a tired phrase, don't know what they don't know.

 

[bravotwozero]

Lol, every year around this time there's a PGY-1/2 asking the same question. Hang in there bud, you'll be alright.

 

[southerndoc]

We all struggle from time to time. Even as an attending with 10 years experience, I sometimes wonder if I'm cut out for it when I have a super busy shift with a lot of difficult patients. During training, you'll ask yourself if you're not built for the specialty. You'll have this during your early attending months as well. Then you'll transition into being comfortable until you have really challenging shifts (very busy, very critical patients, very difficult patients, etc.). Then your mindset changes from if you're built for the specialty into asking yourself if you still have what it takes to continue in the specialty. Burnout is real unfortunately, and I've seen a lot of docs transition to urgent care or other areas.

 

[RoyBasch]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

These all sound like problems that can and will improve with more practice. After your 50th intubation for an unresponsive GCS 3 patient, it will be a "thinking without thinking" moment where you see the patient roll in gurgling in their own secretions and you know its time to prep your airway equipment.

Knee-jerk protocols like sepsis bundles are also just a question of practice.

following up things on multiple patients gets better with time.

Most "critical situations" are ultimately just a question of pattern recognition, and again...practice.

You undervalue how much better you will be 1000 patients from now, 3000 patients from now, and 10000 patients from now. Even young attendings and senior residents are thousands of patients ahead of you.

I do think emergency medicine attracts a certain type of person who is "frequently wrong but never in doubt" personality. These interns and junior residents always seem very confident (and possibly intimidating to their classmates) but as the attending actually hashing out plans with them, I do not find them to be any better

 

[LChristmas]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

Fellow PGY-2 right there with ya buddy. I felt like I got crushed last night and all I can hope for is that I'm better for it tomorrow. Had to lean on my senior and attending last night for something I didn't know how to manage. I try to keep reminding myself that even though I have more responsibility, I'm not supposed to know everything yet.

It also felt nice to commiserate with my classmates after shift, and to know that they're going through the same struggles. We got this!

 

[cyanide12345678]

Early second year is usually the toughest year of residency. Expectations are higher, you see more and push yourself. Knowledge and skills haven't fully developed yet. More or less what you described is normal. Unless of course if in comparison to your second year peers you are severely under performing and are being talked to by the program director with them planning on holding you back - usually that's a good indicator of you not doing well. If your program thinks you're doing okay and is letting you progress further, then you are probably doing okay

 

[RoyBasch]

Early second year is usually the toughest year of residency. Expectations are higher, you see more and push yourself. Knowledge and skills haven't fully developed yet. More or less what you described is normal. Unless of course if in comparison to your second year peers you are severely under performing and are being talked to by the program director with them planning on holding you back - usually that's a good indicator of you not doing well. If your program thinks you're doing okay and is letting you progress further, then you are probably doing okay

I agree with Cyanide, ultimately if you are having a serious problem, your program will be letting you know and they have existing mechanisms to track poor progress and remediation.

My one disagreement though is comparison by talking to your peers. As I noted above, I think EM attracts more of a certain kind of person who likes to flex on their colleagues and seem more confident/skilled then they actually are.

As the attending, I get the check outs from the "Joe Cool" resident PGY-2s who are telling their colleagues they are knocking out 3 patients per hour and resuscitating a septic shock while single-handedly tPA'ing the stroke before talking to the staff. I can tell you when I actually talk to them about their patient's and plans, their thinking is no more clear and they struggle with all the same clinically confounding situations and gray areas as more anxious and timid residents.

Bottom line, your colleagues aren't always the best indicator of their own skills, as there is some ego in play.

Also I can tell you, once I was a chief resident I had access to the actual stats on patients per hour and other metrics. EVERY resident had an inflated sense of how many PPH they were seeing.

 

[thegenius]

Bottom line, your colleagues aren't always the best indicator of their own skills, as there is some ego in play.

Also I can tell you, once I was a chief resident I had access to the actual stats on patients per hour and other metrics. EVERY resident had an inflated sense of how many PPH they were seeing.

There was resident in my program who said he never missed a tube.




I still don't believe him to this day.

 

[The Knife & Gun Club]

There was resident in my program who said he never missed a tube.




I still don't believe him to this day.

Maybe he/she meant like, in summation, they never had an airway which they were unable to secure through some means, eventually?

Like they never had someone die due to lack of airway or never had to call anesthesia for help?

Thats obviously an idiotic interpretation, but the only way I could see that even being vaguely believable.

50% of the time, it works every time.

 

[Birdstrike]

I just started PGY-2, and I'm getting killed. I know every new PGY year has a learning curve, but I feel like I have a personality-level problem. I'm getting overwhelmed by the patient volume, to the point that I'm forgetting basic things like "less than 8, intubate", or considering antibiotics for toxic-appearing tachycardic patients, or even just remembering to check the labs I ordered. I'm also trash with critically ill patients. I get so anxious that I freeze up and have little luck controlling the room effectively. Is this crippling anxiety something people have overcome in this field? Or should I consider switching to another specialty?

The thread title is: "Am I just not built for this specialty?"

Answer: No one is "built for EM." It's something you have to train yourself into, and it doesn't happen in a day, year, or even 3 years. I takes a whole career and I don't think anyone achieves the status of, "Now I'm built for EM." You don't one day all of a sudden roll off an assembly line, The Perfect EM Machine, as ready as you'll ever be, with nowhere to go but down. Maybe some people are built to be great athletes, others fashion models, due to winning the genetic lottery. But no one's built for EM from day 1. It just doesn't work that way.

You confidence and skill will grow overtime. There will be peaks and valleys along the way. July/August of any PGY year (including your first year after residency) is more likely to be a valley, than a peak. Although the learning curve levels off after your first year as an attending, it's never flat.

Maybe there's a career that's a better fit for you out there, maybe there's not, I don't know. But despite outward appearances, I don't think the skill of being an Emergency physician every gets to a point where it's perfected, and the skill is certainly not innate. Just when you think you've seen it all, is about the time you're due to be served something new. If there's one innate skill that makes one fit for EM in comparison to those who are unfit, it's simply having the audacity to show up, give it a shot and show up again. It's also worth remembering you don't own that skill, either. It's on loan to you, and you don't get to keep it forever.

 

[RoyBasch]

It's also worth remembering you don't own that skill, either. It's on loan to you, and you don't get to keep it forever.

Heh you never "own" being a good ER physician; it's on loan, and the rent is due every shift (even after residency).

 

[thegenius]

The thread title is: "Am I just not built for this specialty?"

Answer: No one is "built for EM." It's something you have to train yourself into, and it doesn't happen in a day, year, or even 3 years. I takes a whole career and I don't think anyone achieves the status of, "Now I'm built for EM." You don't one day all of a sudden roll off an assembly line, The Perfect EM Machine, as ready as you'll ever be, with nowhere to go but down. Maybe some people are built to be great athletes, others fashion models, due to winning the genetic lottery. But no one's built for EM from day 1. It just doesn't work that way.

You confidence and skill will grow overtime. There will be peaks and valleys along the way. July/August of any PGY year (including your first year after residency) is more likely to be a valley, than a peak. Although the learning curve levels off after your first year as an attending, it's never flat.

Maybe there's a career that's a better fit for you out there, maybe there's not, I don't know. But despite outward appearances, I don't think the skill of being an Emergency physician every gets to a point where it's perfected, and the skill is certainly not innate. Just when you think you've seen it all, is about the time you're due to be served something new. If there's one innate skill that makes one fit for EM in comparison to those who are unfit, it's simply having the audacity to show up, give it a shot and show up again. It's also worth remembering you don't own that skill, either. It's on loan to you, and you don't get to keep it forever.

With all respect for you, and I have much of that, I either don't totally agree with your statement or it's true for any profession. It doesn't really answer the OP's question.

I think there are people who are "built" for EM. Just like there are people "built" for a lot of jobs or tasks in life. These people are born with some innate abilities and then through hard work become very good at what they do. For instance, M Phelps (Swimmer), M Jordan (Basketball), J. Bogle (Investing), Yo-Yo Ma (Music), J. Garcia (Music), I mean the list goes on and on. For instance, M Phelps is built as an ideal swimmer. His body is perfect for that. And then through tremendous hard work, he became the best. There are numerous people who 1) work as hard as him and never become the best, or 2) are built like him but don't put in as much work at it, lollygag around, and don't become the best. And with EM you don't even need to become the best either.

I absolutely think there are doctors "built" to be ER doctors. Doesn't mean that all of them will be good though. Moreover...there are lots of ER doctors who perhaps weren't built for it but were drawn to the shift work, or the resuscitation part, and through hard work became very good at it.

I think the qualities to becoming an ER physician who is good and enjoys what they do involve three things 1) enjoying resuscitating critically ill patients, 2) knowing a little about a lot of specialties, and 3) enjoying shift-work with schedule day/night. You will be miserable if you have 0 of 3, and probably not be happy even if you have 2/3. Just imagine that you like #1 and #3 but not #2....then you would be suited being like an attending in an academic CICU where all you do is resuscitate and stabilize critically ill heart patients. You would go bonkers if you had to deal with critically ill tox or psych patients.

I agree with some of the other things you wrote. Confidence will grow. You have to work at it. It takes practice. Not sure what you mean by your last sentence though.

 

[Apollyon]

Not sure what you mean by your last sentence though.

I thought he was just referencing skill rot.

 

[thegenius]

I thought he was just referencing skill rot.

Ah.....

This guy plays all the time. Check that out. Honed skillz.

That is hot...but can she do that when she is 50 years old?

Say that to your patients...just like that.

Or say this.....

 

[hopefulgasman]

With all respect for you, and I have much of that, I either don't totally agree with your statement or it's true for any profession. It doesn't really answer the OP's question.

I think there are people who are "built" for EM. Just like there are people "built" for a lot of jobs or tasks in life. These people are born with some innate abilities and then through hard work become very good at what they do. For instance, M Phelps (Swimmer), M Jordan (Basketball), J. Bogle (Investing), Yo-Yo Ma (Music), J. Garcia (Music), I mean the list goes on and on. For instance, M Phelps is built as an ideal swimmer. His body is perfect for that. And then through tremendous hard work, he became the best. There are numerous people who 1) work as hard as him and never become the best, or 2) are built like him but don't put in as much work at it, lollygag around, and don't become the best. And with EM you don't even need to become the best either.

I absolutely think there are doctors "built" to be ER doctors. Doesn't mean that all of them will be good though. Moreover...there are lots of ER doctors who perhaps weren't built for it but were drawn to the shift work, or the resuscitation part, and through hard work became very good at it.

I think the qualities to becoming an ER physician who is good and enjoys what they do involve three things 1) enjoying resuscitating critically ill patients, 2) knowing a little about a lot of specialties, and 3) enjoying shift-work with schedule day/night. You will be miserable if you have 0 of 3, and probably not be happy even if you have 2/3. Just imagine that you like #1 and #3 but not #2....then you would be suited being like an attending in an academic CICU where all you do is resuscitate and stabilize critically ill heart patients. You would go bonkers if you had to deal with critically ill tox or psych patients.

I agree with some of the other things you wrote. Confidence will grow. You have to work at it. It takes practice. Not sure what you mean by your last sentence though.

I hear everything you're saying. My question just has to do with a part of what you're saying. Is enjoying resuscitating critically ill patients truly a requirement or a big 3 as you put it? From my understanding, it is understood that many go into EM because they have a passion for resus, but the truth of the matter is that very little resus is actually performed relatively speaking. As such, it is unwise to go into EM and only EM (no pivoting to crit care) if one solely enjoys EM for resus and cannot tolerate the lower acuity/UC/social aspects of the field (which comprise greater than 90-95% of the specialty and resus making up 5%, maybe 10%).

 

[thegenius]

I hear everything you're saying. My question just has to do with a part of what you're saying. Is enjoying resuscitating critically ill patients truly a requirement or a big 3 as you put it? From my understanding, it is understood that many go into EM because they have a passion for resus, but the truth of the matter is that very little resus is actually performed relatively speaking. As such, it is unwise to go into EM and only EM (no pivoting to crit care) if one solely enjoys EM for resus and cannot tolerate the lower acuity/UC/social aspects of the field (which comprise greater than 90-95% of the specialty and resus making up 5%, maybe 10%).

Yup....I hear ya. We do very little resus, but it's the most important part of this job. Without question we are largely judged by the proverbial EM Gods on how we do with critically ill patients. It's not important if we miss a rheumatological condition that is causing someone's elbow effusion, but it is important if we miss working up, or considering, a PE in someone with chest pain, HR 120, and BP 100/60.

Now a prescient, advanced question arises from your point. If 95% of the patients we see need no resuscitation and 5% do...can be we be really good and happy with our job if we excel with the former and are average (or below average) with the latter? That is a game of brinksmanship I would not want my ER doctor treating me to fall under.

 

[hopefulgasman]

Yup....I hear ya. We do very little resus, but it's the most important part of this job. Without question we are largely judged by the proverbial EM Gods on how we do with critically ill patients. It's not important if we miss a rheumatological condition that is causing someone's elbow effusion, but it is important if we miss working up, or considering, a PE in someone with chest pain, HR 120, and BP 100/60.

Now a prescient, advanced question arises from your point. If 95% of the patients we see need no resuscitation and 5% do...can be we be really good and happy with our job if we excel with the former and are average (or below average) with the latter? That is a game of brinksmanship I would not want my ER doctor treating me to fall under.

I agree and appreciate the insight. I'm not particularly fond of resus, but I'm already locked and loaded into this field as a resident and wonder if I'm going to be in for a world of hurt down the road.

 

[thegenius]

I agree and appreciate the insight. I'm not particularly fond of resus, but I'm already locked and loaded into this field as a resident and wonder if I'm going to be in for a world of hurt down the road.

I don't think so...I was scared of resus in residency and still am to some degree this day. I don't "jump" on every sick patient that comes to the ED. Actually...most resus is fun there are just a few things that I still get scared about...and the main one is treating hypotensive bradycardia that requires TV pacing. I seem to get that once every 1-2 years and I usually have gotten lucky as they come in during the day and I call cardiology.

I think what I'm bothered by now are patients who need something done (a line, LP, a procedure, even IVF) and it can't be done because they are too fat or squirrely or whatever...and it needs to be done now because they are really sick. I can't stand that stuff because it backs up my time and the ED.

I do like ER and there are a ton of sick patients that come in that I improve them immediately. It's fun like that.

 

[Birdstrike]

Not sure what you mean by your last sentence though.

I meant it literally, @RoyBasch got it. To whatever extent you've built yourself to be fit to be an ER doc, intellectually, psychologically, emotionally, or physically, is not yours to keep forever. In other words, you may have it today, but you won't have it forever. You don't own it, it's on loan to you. There will be a day, you say, "I can't do this anymore," and you won't be able to do it anymore.

 

[Birdstrike]

I thought he was just referencing skill rot.

It could be skill rot. It could be from losing the desire, losing the physical ability, or emotional exhaustion. Either way, the fuse burns.

 

[kortney.krupsky1002]

Could it just be the long hours wearing you down? Maybe these tips could help.