Doing poorly in fellowship

[SilverCat]

Hi,

I'm not sure how many people have experience with this, but just need advice about doing poorly in fellowship. I'm starting second year in a non competitive fellowship, but am doing worse than new first years.

My worst problem is extreme inefficiency--I have a terrible memory, so I have to chart review way more than I should regarding a patient's history. I forgot and mix details when rounding-- usually because my handwriting is terrible, and that's the only way I pre chart due to inefficiency.

On top of that, I have a tendency to spend too much time in patients' rooms, which is particularly bad when you have 10-15 patients to see, often when a patient is chatty. So of course I never finish seeing patients, which looks terrible for a second year fellow who should have it together.

My knowledge is also pretty poor. With all of this going on, I've had feedback saying that I look disinterested, so now I'm in danger of probation per my program if things don't improve. I look disinterested because I'm doing so poorly I feel depressed being on service.

Just ready to leave--even if I finish fellowship, I probably won't have any good recommendations to get a good job. Feeling extremely depressed and just ready to quit.

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[IMGASMD]

-considering talk to someone. If you can identify some of the feelings are from depression. Starting a low dose anti-depressant may help.
- write better. So YOU can read it.
- do you really need to present every patient with every single details? I’d imagine that as a second year fellow, you should know what’re you’re interested pertinent positives and negatives…. I trained in the age of paper chart. Only some of that copy and paste stuff.
- don’t worry about your job yet, get through this first, and you can always fall back on IM.

Nothing very specific, but need to start somewhere.

 

[Kaustikos]

Hi,

I'm not sure how many people have experience with this, but just need advice about doing poorly in fellowship. I'm starting second year in a non competitive fellowship, but am doing worse than new first years.

My worst problem is extreme inefficiency--I have a terrible memory, so I have to chart review way more than I should regarding a patient's history. I forgot and mix details when rounding-- usually because my handwriting is terrible, and that's the only way I pre chart due to inefficiency.

On top of that, I have a tendency to spend too much time in patients' rooms, which is particularly bad when you have 10-15 patients to see, often when a patient is chatty. So of course I never finish seeing patients, which looks terrible for a second year fellow who should have it together.

My knowledge is also pretty poor. With all of this going on, I've had feedback saying that I look disinterested, so now I'm in danger of probation per my program if things don't improve. I look disinterested because I'm doing so poorly I feel depressed being on service.

Just ready to leave--even if I finish fellowship, I probably won't have any good recommendations to get a good job. Feeling extremely depressed and just ready to quit.

I have some concerns but the issues you present don't give me enough information to make an informed decision.

When did this all start happening? Were you happy when you started your fellowship in the beginning? Did this all of sudden start happening recently?

Do you enjoy the fellowship? Why did you apply for this fellowship?

Do you have other colleagues you work with? If so, how do they feel? How did your seniors feel?

Has your program addressed these issues in the sense of asking how you feel? Asking if anything is bothering you? Programs don't win by putting people on probation. Or dismissing. At Fellowship, they want you to succeed. So, it seems like I'm not getting the whole picture in terms of how they're approaching you about this. You mention "seeming disinterested". What have you said? Are you being honest with them about how you feel? You should treat your fellowship like a real job; if people notice something is off and you feel it, you need to bring it up before it's too late. Especially when you have this much vested in you. If you don't bring this up or fix this soon, you're not going to have much of a fight.

I would strongly recommend talking to your director or seeking help.

Lastly, your knowledge is not poor. If you're licensed and graduated from residency, then making the excuse about your knowledge isn't accurate.

 

[SilverCat]

Thanks for the thoughtful replies. I was happy initially but after multiple rotations, feel that I have inadequacies in terms of keeping up with the details of the patient's histories and not missing key things. Also, very inefficient--have tried multiple methods to fix this, all without success. I have no memory whatsoever. I've also had trouble keeping on top of all of the paperwork, modules for training, etc. My PD is very supportive, so that's not an issue and my colleagues are happy. It's just a problem with me.

My big insecurity is that although I come in earlier and stay later than everyone, I'm still doing so terribly. Even though I'm the senior fellow on the team, the medical students will look to the junior fellow for advice and directions. I'm just ready to do something where I don't feel like garbage everyday.

 

[SilverCat]

Thanks for the thoughtful replies. I was happy initially but after multiple rotations, feel that I have inadequacies in terms of keeping up with the details of the patient's histories and not missing key things. Also, very inefficient--have tried multiple methods to fix this, all without success. I have no memory whatsoever. I've also had trouble keeping on top of all of the paperwork, modules for training, etc. My PD is very supportive, so that's not an issue and my colleagues are happy. It's just a problem with me.

My big insecurity is that although I come in earlier and stay later than everyone, I'm still doing so terribly. Even though I'm the senior fellow on the team, the medical students will look to the junior fellow for advice and directions. I'm just ready to do something where I don't feel like garbage everyday.

I've also asked for feedback from attendings on rotations, I never hear anything bad, but my PD is hearing that I don't appear interested.

 

[mszzeta]

Hi,

I'm not sure how many people have experience with this, but just need advice about doing poorly in fellowship. I'm starting second year in a non competitive fellowship, but am doing worse than new first years.

My worst problem is extreme inefficiency--I have a terrible memory, so I have to chart review way more than I should regarding a patient's history. I forgot and mix details when rounding-- usually because my handwriting is terrible, and that's the only way I pre chart due to inefficiency.

On top of that, I have a tendency to spend too much time in patients' rooms, which is particularly bad when you have 10-15 patients to see, often when a patient is chatty. So of course I never finish seeing patients, which looks terrible for a second year fellow who should have it together.

My knowledge is also pretty poor. With all of this going on, I've had feedback saying that I look disinterested, so now I'm in danger of probation per my program if things don't improve. I look disinterested because I'm doing so poorly I feel depressed being on service.

Just ready to leave--even if I finish fellowship, I probably won't have any good recommendations to get a good job. Feeling extremely depressed and just ready to quit.

1. You are still in training and have a whole year (I assume you are in a 2-year fellowship) to improve. This is why the fellowship is 2 years, not 1 year. You should be confident that you can be competent with another year of training

2. Don't worry about job at all. Most community jobs only care if you are board eligible or not. I mean this literally. Also, for certain specialties (such as rheum or endo), many jobs are 100% outpatient. So your inpatient competence matters little

3. I had the same issue of "over chart review", to try to know the patient as best as possible. If you have a long list, it is practical to be highly focused on the consult question and prioritizing the most pertinent information. It is totally ok if the attending asks something peripheral that you don't know (some attendings like to ask peripheral questions, such as what some random lab value is 5 years ago......I felt stressed myself too initially)

4. For the patient encounter, similarly, you can try to be more focused. We were told in medical school to be a good listener and emphatic to the patients' story. However, it may just not be practical and you need to let some patients down to make yourself not burnout (otherwise, you will let more patients down in the long term).

 

[SilverCat]

1. You are still in training and have a whole year (I assume you are in a 2-year fellowship) to improve. This is why the fellowship is 2 years, not 1 year. You should be confident that you can be competent with another year of training

2. Don't worry about job at all. Most community jobs only care if you are board eligible or not. I mean this literally. Also, for certain specialties (such as rheum or endo), many jobs are 100% outpatient. So your inpatient competence matters little

3. I had the same issue of "over chart review", to try to know the patient as best as possible. If you have a long list, it is practical to be highly focused on the consult question and prioritizing the most pertinent information. It is totally ok if the attending asks something peripheral that you don't know (some attendings like to ask peripheral questions, such as what some random lab value is 5 years ago......I felt stressed myself too initially)

4. For the patient encounter, similarly, you can try to be more focused. We were told in medical school to be a good listener and emphatic to the patients' story. However, it may just not be practical and you need to let some patients down to make yourself not burnout (otherwise, you will let more patients down in the long term).

I only have one more month for clinical rotations--research is after this.l--so no further clinical training.

 

[rokshana]

Hi,

I'm not sure how many people have experience with this, but just need advice about doing poorly in fellowship. I'm starting second year in a non competitive fellowship, but am doing worse than new first years.

My worst problem is extreme inefficiency--I have a terrible memory, so I have to chart review way more than I should regarding a patient's history. I forgot and mix details when rounding-- usually because my handwriting is terrible, and that's the only way I pre chart due to inefficiency.

On top of that, I have a tendency to spend too much time in patients' rooms, which is particularly bad when you have 10-15 patients to see, often when a patient is chatty. So of course I never finish seeing patients, which looks terrible for a second year fellow who should have it together.

My knowledge is also pretty poor. With all of this going on, I've had feedback saying that I look disinterested, so now I'm in danger of probation per my program if things don't improve. I look disinterested because I'm doing so poorly I feel depressed being on service.

Just ready to leave--even if I finish fellowship, I probably won't have any good recommendations to get a good job. Feeling extremely depressed and just ready to quit.

How were you in residency? Were these issues then?

 

[mszzeta]

I only have one more month for clinical rotations--research is after this.l--so no further clinical training.

If you do feel uncomfortable with inpatient consult, and your specialty practice involves a lot of these, you can probably ask your PD to switch your research to inpatient.

Research is really useless if you don't plan to do academic. And your PD should be very happy for having you (and your patients) not be in big trouble after fellowship.

If you are in rheum or endo, just ignore this. Inpatient consult skills are useless for most practice......

 

[rokshana]

If you do feel uncomfortable with inpatient consult, and your specialty practice involves a lot of these, you can probably ask your PD to switch your research to inpatient.

Research is really useless if you don't plan to do academic. And your PD should be very happy for having you (and your patients) not be in big trouble after fellowship.

If you are in rheum or endo, just ignore this. Inpatient consult skills are useless for most practice......

Umm are you either rheum or endo?
Im endo…and do significant amount of inpt…because there is a need.

 

[dozitgetchahi]

Umm are you either rheum or endo?
Im endo…and do significant amount of inpt…because their is a need.

I’m rheum. I do zero inpatient and so do most other non-academic rheums at the moment.

And I actually kinda agree with his statement about inpatient consult skills not translating well to the outpatient side, at least in rheumatology. My rheum fellowship hammered us with inpatient consult rotations, and we had huge censuses when we were on. Attendings acted like it was such a big deal that we be able to go see 10 new complex rheum consults in time to round by 11am, etc. All this is great when I encounter a really sick lupus patient, GPA etc - but does it matter when I tackle the bread and butter RA, PsA, gout etc etc that forms probably 80-90% of my current practice? No, no it does not.

A lot of things that are emphasized in fellowship training end up being not all that important in the real world…plus, in clinic as an attending you can generally set things up your way, and you have support staff whose job it is to chase records and do much of the drudgework that gets forced on you as a fellow. It’s really hard to tell how OP might be doing without being there to see him/her work.

I’ll also say that the chance of them putting someone on probation during a two year fellowship is low unless someone is really underperforming - hell at this point OP is past the halfway point. If OP is putting in a good faith effort, staying late and getting there early etc, he may well be doing OK even if he doesn’t feel like it. (Also, if it’s actually true that OP has no more clinical training on the upcoming agenda and he’s just doing research for the rest of the fellowship, then he is especially unlikely to have anything else really happen to him.)

That said, I agree with the question “how were you doing in residency?” Also, OP’s statement that he has “no memory” seems like it could be concerning for a doctor, and again it’s hard to know what OP is referring to here without being there (poor working memory? No ability to form new memories? Poor focus/ADHD? Etc)…there’s a huge difference between just not having a fantastic memory and truly having trouble storing significant memories, which for a physician would seem to be a critical function…

 

[rokshana]

I’m rheum. I do zero inpatient and so do most other non-academic rheums at the moment.

And I actually kinda agree with his statement about inpatient consult skills not translating well to the outpatient side, at least in rheumatology. My rheum fellowship hammered us with inpatient consult rotations, and we had huge censuses when we were on. Attendings acted like it was such a big deal that we be able to go see 10 new complex rheum consults in time to round by 11am, etc. All this is great when I encounter a really sick lupus patient, GPA etc - but does it matter when I tackle the bread and butter RA, PsA, gout etc etc that forms probably 80-90% of my current practice? No, no it does not.

A lot of things that are emphasized in fellowship training end up being not all that important in the real world…plus, in clinic as an attending you can generally set things up your way, and you have support staff whose job it is to chase records and do much of the drudgework that gets forced on you as a fellow. It’s really hard to tell how OP might be doing without being there to see him/her work.

I’ll also say that the chance of them putting someone on probation during a two year fellowship is low unless someone is really underperforming - hell at this point OP is past the halfway point. If OP is putting in a good faith effort, staying late and getting there early etc, he may well be doing OK even if he doesn’t feel like it. (Also, if it’s actually true that OP has no more clinical training on the upcoming agenda and he’s just doing research for the rest of the fellowship, then he is especially unlikely to have anything else really happen to him.)

That said, I agree with the question “how were you doing in residency?” Also, OP’s statement that he has “no memory” seems like it could be concerning for a doctor, and again it’s hard to know what OP is referring to here without being there (poor working memory? No ability to form new memories? Poor focus/ADHD? Etc)…there’s a huge difference between just not having a fantastic memory and truly having trouble storing significant memories, which for a physician would seem to be a critical function…

Interesting that where you were that rheum did so much inpt… where I did residency, rheum didn’t have that much of a presence inpt, the focus was more outpt…where I did fellowship, we only spent about a third of our rotations doing inpt…can you do endo w/o doing inpt consults, yes, many do, but can easily have significant inpt consults, especially of offering a glucose service.

 

[SilverCat]

Residency was also difficult for me--I struggled with the same issues, but they seem to be progressively worsening. I majorly struggle to keep up with administrative paperwork, like logging cases, filling out on boarding forms for each hospital rotation, etc. there's also the ten million training modules thatI'm always behind in. When I say memory issues- I mean I can't remember details about the patient's admission--why they were admitted, ongoing issues of note for my fellowship, therapies and durations of therapy. I would have thought my difficulty with communication would be an issue, but interestingly wasn't brought up by my PD during our meeting.

I'm neither rheum nor endo, just FYI.

 

[CluvK]

OP, I guess you are doing ID that programs used to have a hard time recruiting new fellows. ID is definitely getting more competitive but yeah you know what I mean. You will be fine.

It seems you have workflow issues and they will be better when you become attending. You can have more control over practice setups. If you are running behind and don't know what to say over the phone when someone consults you, you can always say vancomycin + meropenem + micafungin (just kidding), and sit back.

 

[Kaustikos]

OP, I guess you are doing ID that programs used to have a hard time recruiting new fellows. ID is definitely getting more competitive but yeah you know what I mean. You will be fine.

It seems you have workflow issues and they will be better when you become attending. You can have more control over practice setups. If you are running behind and don't know what to say over the phone when someone consults you, you can always say vancomycin + meropenem + micafungin (just kidding), and sit back.

If OP is doing ID, then I'm actually more concerned. I don't think they're doing ID Fellowship, they should be doing better than 1st years.

 

[SilverCat]

If OP is doing ID, then I'm actually more concerned. I don't think they're doing ID Fellowship, they should be doing better than 1st years.

I am ID actually. Added to the above issues, I also struggle significantly with communication (really dread going in and talking with patients). I love learning about ID and thinking through patient cases, but talking with patients and their families brigs out a deep-seated dread.

The next logical question I guess would be why I chose medicine. Probably for the wrong reasons--a lot of people told me I wasn't cut out for medicine because of my introverted personality and I wanted to prove them wrong. So now I'm stuck with 200k debt and possibility of termination from fellowship. I honestly can't imagine working as a hospitalist, having family goals of care conversations and dealing with disposition. Honestly have no idea how I was allowed to graduate residency, but I was never in this kind of trouble.

Sorry this comes across as an extremely whiny and ungrateful post.

 

[Kaustikos]

I am ID actually.

Again, there's the concern I had from before.
Not sure why you were hesitant to bring up what your specialty is now but it still is concerning you haven't discussed it with your attendings in greater length.
How have you performed on your in-service exams?
How late are you staying? How many patients do you have/day? How many weeks of service do you have?

- edit -
I'm more concerned about the fellowship program than OP. It just doesn't make sense that they're saying OP is doing fine so casually.

 

[SilverCat]

Again, there's the concern I had from before.
Not sure why you were hesitant to bring up what your specialty is now but it still is concerning you haven't discussed it with your attendings in greater length.
How have you performed on your in-service exams?
How late are you staying? How many patients do you have/day? How many weeks of service do you have?

Mainly because I didn't want to be identified. Actually have discussed it with my PD. In service exam 75th percentile last year. On a rotation where we round from 1-6 or PM, I'm there from 8 am (to prechart, see new one and old patients) to 9:30 PM. Usually have 12 patients a day +2-3 new ones. Only have 7 weeks of service left.

 

[Kaustikos]

Mainly because I didn't want to be identified. Actually have discussed it with my PD. In service exam 75th percentile last year. On a rotation where we round from 1-6 or PM, I'm there from 8 am (to prechart, see new one and old patients) to 9:30 PM. Usually have 12 patients a day +2-3 new ones. Only have 7 weeks of service left.

OP...

"Poor knowledge and no memory"

"75th percentile"

2+2 = 5?

 

[SilverCat]

OP...

"Poor knowledge and no memory"

"75th percentile"

2+2 = 5?

I've always been a good test taker--doesn't really correlate to my clinical evaluations

 

[Kaustikos]

I've always been a good test taker--doesn't really correlate to my clinical evaluations

I'm looking back and even more confused.
They tell you you're doing fine and then say you're at risk of probation.

Again, the Attending should be giving you feedback after each service. You should be getting evaluations twice a year and basically should say you're doing great/on your way. So, I'm more concerned because you should be feeling more comfortable at this point. Or your program should've been intervening better.

 

[emergentmd]

On a rotation where we round from 1-6 or PM, I'm there from 8 am (to prechart, see new one and old patients) to 9:30 PM. Usually have 12 patients a day +2-3 new ones. Only have 7 weeks of service left.

I do not know much about ID but if you are taking 13+ hrs a day to see 2-3 new pts plus 12 old pts then you are 5 standard of deviations from the norm. No way you can be a hospitalists where you may have 20+ floor pts plus 10+ new pts in your 12 hr shifts.

Doesn't look like ID will be for you. Finish or not, you need to move into something not related to doing hospital work.

 

[SilverCat]

I do not know much about ID but if you are taking 13+ hrs a day to see 2-3 new pts plus 12 old pts then you are 5 standard of deviations from the norm. No way you can be a hospitalists where you may have 20+ floor pts plus 10+ new pts in your 12 hr shifts.

Doesn't look like ID will be for you. Finish or not, you need to love into something not related to doing hospital work.

Lol--I see and chart review those patient before 1 PM, then the team rounds from 1 PM-7 PM. I'm bad, but not quite that bad.

 

[Kaustikos]

Lol--I see and chart review those patient before 1 PM, then the team rounds from 1 PM-7 PM. I'm bad, but not quite that bad.

Well, realistically, it's hard for me to say more without more information.
Majority of ID is inpatient. Yes, there are some hospitals/programs/groups that allow one to do mostly outpatient but that usually involves a large group and mostly HIV patients. But there still has some inpatient involvement.

What career are you looking for?

 

[CluvK]

I am ID actually. Added to the above issues, I also struggle significantly with communication (really dread going in and talking with patients). I love learning about ID and thinking through patient cases, but talking with patients and their families brigs out a deep-seated dread.

The next logical question I guess would be why I chose medicine. Probably for the wrong reasons--a lot of people told me I wasn't cut out for medicine because of my introverted personality and I wanted to prove them wrong. So now I'm stuck with 200k debt and possibility of termination from fellowship. I honestly can't imagine working as a hospitalist, having family goals of care conversations and dealing with disposition. Honestly have no idea how I was allowed to graduate residency, but I was never in this kind of trouble.

Sorry this comes across as an extremely whiny and ungrateful post.

FWIW, I am still early in my stage of training. I think you will be fine. Look, 75% percentile in-service score, which could mean a good knowledge base. You feel you are doing worse than 1st-year fellow. But is it true? You are "introverted" and might not show off your smart brain. Medicine is kind of like acting. Did you remember those days preparing for Step 2 CS? Be confident.

In terms of workflow, you are on consult service and are not supposed to manage hospitalists' jobs. When patients ask you something that you don't know, can defer to the primary team. Don't feel bad for doing it. Even if you quit ID for whatever reasons, PCP is always an option for you, and your knowledge and experience in HIV can be extremely helpful. I understand hospitalist is not for every internist.

 

[wholeheartedly]

OP (disclaimer I’m not a physician), but you seem to be having trouble with organizing your information and focusing. Did you have trouble with this is med school?

I wonder if seeing a professional to assess if there are underlying issues behind this (depression, anxiety, learning disorder, etc) and if so there are likely some interventions that would help from behavioral to learning strategies.

If you love ID and not patient interaction would a 1 year medical microbiology fellowship after your ID fellowship maybe be a better fit than clinical practice with patients? There are ID docs that go that route and having the ID experience on the patient side could help inform the clin micro side. just a thought. Maybe you could use your research year to explore that direction and set yourself up to shift into it…

 

[dozitgetchahi]

Residency was also difficult for me--I struggled with the same issues, but they seem to be progressively worsening. I majorly struggle to keep up with administrative paperwork, like logging cases, filling out on boarding forms for each hospital rotation, etc. there's also the ten million training modules thatI'm always behind in. When I say memory issues- I mean I can't remember details about the patient's admission--why they were admitted, ongoing issues of note for my fellowship, therapies and durations of therapy. I would have thought my difficulty with communication would be an issue, but interestingly wasn't brought up by my PD during our meeting.

I'm neither rheum nor endo, just FYI.

At least in the real world a lot of that admin paperwork can be dumped onto support staff to get it out of your hair…one of the more shocking aspects of transitioning out of training was that institutions will actually try to help you be happy and make your work environment more pleasant, and that means having people available to help take (at least some) of that type of crap off your shoulders for you.

I agree that the fellowship program seems disconnected here. Something doesn’t really add up.

 

[rokshana]

Have you thought of doing something not pt related per se? CDC? FDA?

 

[dozitgetchahi]

I am ID actually. Added to the above issues, I also struggle significantly with communication (really dread going in and talking with patients). I love learning about ID and thinking through patient cases, but talking with patients and their families brigs out a deep-seated dread.

The next logical question I guess would be why I chose medicine. Probably for the wrong reasons--a lot of people told me I wasn't cut out for medicine because of my introverted personality and I wanted to prove them wrong. So now I'm stuck with 200k debt and possibility of termination from fellowship. I honestly can't imagine working as a hospitalist, having family goals of care conversations and dealing with disposition. Honestly have no idea how I was allowed to graduate residency, but I was never in this kind of trouble.

Sorry this comes across as an extremely whiny and ungrateful post.

Having an introverted personality itself isn’t a problem in medicine - hell, there are plenty of places (pathology, radiology, etc) where those types of folks hang out. The choice of IM may have been a bit of an issue, but I agree that medical microbiology may be a good place for you if nothing else.

If you dread patient contact that much, maybe something to consider is to sit down with your PD and ask if he’ll provide a rec letter to get you into the match to retrain in a specialty for which you might be better suited…or do you like research? Maybe ID research would be a good fit?

 

[wholeheartedly]

Agree, CDC, FDA, NIH, state and local public health orgs, and industry are also options.

Is this a program where you could use your research year to get an MS in Clinical research or MS/MPH Epidemiology, preferably funded?

 

[mszzeta]

Agree, CDC, FDA, NIH, state and local public health orgs, and industry are also options.

Is this a program where you could use your research year to get an MS in Clinical research or MS/MPH Epidemiology, preferably funded?

I am not sure why people are such harsh.

OP scored 75% on his ITE exam. And the program leadership has not identified any red flag on his clinical competence. And additionally, he has a whole year to improve his clinical skills. He will also gain much more knowledge from preparing board exam

I know many clinician said they continued to learn tremendously from practice after they graduated from fellowship. I see ABSOLUATELY NO reason to believe OP needs to consider a non-clinical career at this time, from a competence perspective

 

[wholeheartedly]

I am not sure why people are such harsh.

OP scored 75% on his ITE exam. And the program leadership has not identified any red flag on his clinical competence. And additionally, he has a whole year to improve his clinical skills. He will also gain much more knowledge from preparing board exam

I know many clinician said they continued to learn tremendously from practice after they graduated from fellowship. I see ABSOLUATELY NO reason to believe OP needs to consider a non-clinical career at this time, from a competence perspective

The OP expressed being uncomfortable with patient interaction, so we were giving other possible options.

 

[rokshana]

I am not sure why people are such harsh.

OP scored 75% on his ITE exam. And the program leadership has not identified any red flag on his clinical competence. And additionally, he has a whole year to improve his clinical skills. He will also gain much more knowledge from preparing board exam

I know many clinician said they continued to learn tremendously from practice after they graduated from fellowship. I see ABSOLUATELY NO reason to believe OP needs to consider a non-clinical career at this time, from a competence perspective

Did you even read the OP’s post?
And what is “harsh” about recommending non clinical path to someone, who apparently is book smart…as attested by his ITE scores, but themselves notes that they have poor clinical skills…pushing them further down a path that is not their strength is not good advice.
And it is pointedly mentioned that after this month, they are on research for the rest of their fellowship.
Clinical medicine isn’t what everyone with an MD/DO has to do.

 

[mszzeta]

Did you even read the OP’s post?
And what is “harsh” about recommending non clinical path to someone, who apparently is book smart…as attested by his ITE scores, but themselves notes that they have poor clinical skills…pushing them further down a path that is not their strength is not good advice.
And it is pointedly mentioned that after this month, they are on research for the rest of their fellowship.
Clinical medicine isn’t what everyone with an MD/DO has to do.

It is true that OP is not subjectively feeling well. But 1. How much do you know about his objective performance? It is the program's responsibility of removing an incompetent physician from graduation, apparently this is not the case for OP. 2. People can change and improve. OP has been in a subspeciality for only one year. People continue to improve their clinical practice even years after training.

Last but not the least, All the post is about a subspeciality. I have seen zero reason why OP cannot practice either hospital medicine or PCP, even if he quits fellowship.

The most important question for a job is not necessary "being comfortable" or "like", but being "competent". Many people don't feel comfortable at all during the first few months of being an attending. Things can change and improve

 

[SilverCat]

I have thought of medical micro fellowship, just dread the thought of being in debt forever, as salary is not as good as that of a practicing physician. However, at this point, I highly doubt I would be functional as a practicing physician, with poor communication skills and inability to complete basic requirements of paperwork. Just feel like a massive failure overall, and am tempted to just ask to leave fellowship before I'm kicked out.

 

[rokshana]

I have thought of medical micro fellowship, just dread the thought of being in debt forever, as salary is not as good as that of a practicing physician. However, at this point, I highly doubt I would be functional as a practicing physician, with poor communication skills and inability to complete basic requirements of paperwork. Just feel like a massive failure overall, and am tempted to just ask to leave fellowship before I'm kicked out.

Eh… you have less than a year and the rest of that is research… finish the fellowship so you have the creds and look for something that works with your strengths… you would be surprised at how much you can make working for cdc, fda, world bank, etc…

 

[Redpancreas]

I’m not in fellowship but I have a lot of training experience and have been through remediation efforts. I also recognize your username from a long time ago and remember you had pretty good numbers coming into medical school (ie GPA/MCAT) so I wanted to weigh in. I’m not an ID physician or fellow but I have a decent understanding of the fellow’s role with many friends at that stage. I think I have a gestalt about what’s going on and hopefully may have some productive suggestions. I may be completely off though so take this with a grain of salt. If it’s not, I was just trying to help. I state everything as if it’s reality moving forward because it’s too cumbersome to keep writing, I think…suspect, etc. but the following is speculation.

I think the first thing that clued me into what’s causing your struggles was that you struggled in residency a bit. While IM may seem redundant/secretarial by the end of it, it’s supposed to train you to be complete, efficient, and organized. All the above are necessary to be a good fellow. Right now, I think there are gaps in those skills. Before you improve in fellowship, you need to go back to think about your IM best practices for a week or so. Build some of those habits back up or just build new good habits fast and stick to them. It’s not as hard as you think. It requires some deliberation. There should be a core set of questions you ask every patient in the morning with some tailoring to the consult. Your exam should be the same order/habit on every patient with some tailoring to the individual case. Your differential should be complete (as a product of your book knowledge which should come naturally to you) and focused/accurate from your ID experience from things like pattern recognition. If you haven’t mastered the basics (complete, organized, efficient) then you will be forever bogged down with the basics and won’t have the bandwidth to think about ID fellow level stuff, pattern recognize, and gain the clinical reasoning needed for ID.

Some other miscellaneous thoughts:

1.) Remembering random dates like EOTs on OPATs, Abx courses and that stuff comes from how you organize your patient cases in your mind/paper, not how inherently potent your cerebral cortex is. I guarantee that if you start writing this information in one place for each patient your memory will miraculously improve. Your issue is organization which ultimately is not a failure of your personality or related to a neurotransmitter deficiency in your brain. It’s related to your tendency to stray from routine/habit for whatever reason. Additionally, Depression can also mimic memory issues but I think in your case it’s less about memory and more about organization.

2.) I do think your relative incompetence has led to some form of unspecified anxiety/depression and that is doing two things. One is that it’s amplifying every little problem that is occurring which keeps you out of the present and two is it’s keeping your stress/cortisol level always on. I don’t know the mechanism or the best way to explain it but some learning comes when you are in rapid fire mode under duress. Some learning/epiphanies come from when you’re super relaxed. Think about any good ideas you’ve had in the past. You’re chronic depressed/stressed state is stunting that learning phase. .

3.) It’s the second month of the new academic medicine year. Everyone is being inundated with modules specific to their department, multiple hospital assignments, emrs, and logs/evals which are usually up for renewal this part of the year. The administrative burden you’re feeling right now likely isn’t unique to you. I’ll bet if you reached out to some colleagues, they’ll share the same concerns.

4. Speaking of that, I wouldn’t be surprised if you reached out to your colleagues and they had the same insecurities.

 

[anonperson]

Hi,

I'm not sure how many people have experience with this, but just need advice about doing poorly in fellowship. I'm starting second year in a non competitive fellowship, but am doing worse than new first years.

My worst problem is extreme inefficiency--I have a terrible memory, so I have to chart review way more than I should regarding a patient's history. I forgot and mix details when rounding-- usually because my handwriting is terrible, and that's the only way I pre chart due to inefficiency.

On top of that, I have a tendency to spend too much time in patients' rooms, which is particularly bad when you have 10-15 patients to see, often when a patient is chatty. So of course I never finish seeing patients, which looks terrible for a second year fellow who should have it together.

My knowledge is also pretty poor. With all of this going on, I've had feedback saying that I look disinterested, so now I'm in danger of probation per my program if things don't improve. I look disinterested because I'm doing so poorly I feel depressed being on service.

Just ready to leave--even if I finish fellowship, I probably won't have any good recommendations to get a good job. Feeling extremely depressed and just ready to quit.

Your memory is fine. If you've graduated medical school and residency and entered fellowship, you can't use that excuse. Your memory is probably a standard deviation above the norm by virtue of being a physician.

Rule out any medical or psychiatric issue ( depression etc).

Quit chatting with patients. They aren't your friends.

You are a fellow, the residents and medical students should be doing a decent bit of the scut work.

If your knowledge is poor, then study. Sit down and read when you get home. If you need to make flash cards etc, so be it.

When I was studying for my oral board exams, I had to know various guidelines cold so I could recite them perfectly from memory.

I would test myself randomly and if I didn't know them immediately I sat down and brute force memorized them.

If you read/study, you will be faster and more confident. Once that happens, the job becomes more enjoyable and easier even if you aren't necessaril fond of the specialty.

 

[Kaustikos]

Quit chatting with patients. They aren't your friends.

You are a fellow, the residents and medical students should be doing a decent bit of the scut work..

This is monumentally instrumental. I don't spend more than 10-15 minutes on follow ups. If the patient even mutters a question about something non-infectious, I just interrupt and tell them to speak to the nurse or hospitalist. I went into this fellowship to deal with this specialty, not the other bulls.hit.

 

[HemeOncHopeful19]

This is monumentally instrumental. I don't spend more than 10-15 minutes on follow ups. If the patient even mutters a question about something non-infectious, I just interrupt and tell them to speak to the nurse or hospitalist. I went into this fellowship to deal with this specialty, not the other bulls.hit.

“Yeah I don’t know much about that / you don’t want me to handle that trust me, I’ll let your primary team/heart doctor/the janitor do what they do best while I focus on your infection”

 

[Drrrrrr. Celty]

This is monumentally instrumental. I don't spend more than 10-15 minutes on follow ups. If the patient even mutters a question about something non-infectious, I just interrupt and tell them to speak to the nurse or hospitalist. I went into this fellowship to deal with this specialty, not the other bulls.hit.

I feel like I spend a lot more time trying to track down the nurses and ask for them explain whether they gave insulin, got a stim test, or trying to generally deal with my crappy EMR than I talk to patients half these days...

kind of feels bad.

 

[ROBINHO]

Identify high performing fellows and shadow them or talk to them about what they do to be efficient.
Sometimes you can learn from your peers

Difficult to advise in a public forum without all the facts. Sit down with your PD and let him/her know that you want to improve and you can go through your evaluations and identify what you need to work on

If you dont turn things around thisyear , chances are that you will also struggle as an attending when work load is even bigger.