Getting chewed out in IM

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Uafl112

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I started IM this week and I've found out that I'm pretty bad at making assessments/plans. I figured I'd be decent at it at this level given my step 1 score, but apparently not lol. Got chewed out every day this week by the attending cause my A/Ps were just terrible. It was discouraging to the point that I was considering not doing IM as a residency. Is this normal for a 3rd year on his 2nd rotation of the year? Cause the attending made it seem like I should be good at this. Tips on improving? thanks

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I started IM this week and I've found out that I'm pretty bad at making assessments/plans. I figured I'd be decent at it at this level given my step 1 score, but apparently not lol. Got chewed out every day this week by the attending cause my A/Ps were just terrible. It was discouraging to the point that I was considering not doing IM as a residency. Is this normal for a 3rd year on his 2nd rotation of the year? Cause the attending made it seem like I should be good at this. Tips on improving? thanks
It's difficult in July, because your attending probably heard some good assessments as far as medical student presentations from the advancing 3rd years. The attending may also not realise you are a newer student since this is just July.

As far as doing A/P, it generally takes 4th/5th rotation before, as a resident, I begin to see decent assessments. The biggest thing is organization. Do bigger problems first and then the smaller ones. Some people prefer system based presentations rather than problem based. The other thing would be to practice your assessments. Generally, when you look bad, your residents look bad. So practice with your residents. Practice with your classmates, practice in your own head. I used to have to present 4-5 times in my head before I could do an OK job during rounds and this was like my 5th rotation. It was midway in 4th year, before I could and do less practice.
 
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It's difficult in July, because your attending probably heard some good assessments as far as medical student presentations from the advancing 3rd years. The attending may also not realise you are a newer student since this is just July.

As far as doing A/P, it generally takes 4th/5th rotation before, as a resident, I begin to see decent assessments. The biggest thing is organization. Do bigger problems first and then the smaller ones. Some people prefer system based presentations rather than problem based. The other thing would be to practice your assessments. Generally, when you look bad, your residents look bad. So practice with your residents. Practice with your classmates, practice in your own head. I used to have to present 4-5 times in my head before I could do an OK job during rounds and this was like my 5th rotation. It was midway in 4th year, before I could and do less practice.

ok ill definitely try that out! I guess reading and Uworld will naturally help as well right?
 
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First, I would argue that if you're getting feedback about your A and P you're probably doing rather well. This is far and away the most difficult part and is really the goal of your whole next two years. It suggests you're at a level appropriate stage.

The fundamental skill underlying this aspect of presentation is being able to succinctly identify the patients active medical issues and prioritize and/or organize them appropriately. In some cases this calls for you to state a diagnosis or at least a differential. Sometimes it's not readily apparent what the active issues are, especially for a more complex patient. This is one of the skills you're developing this year and your A and P is where it becomes obvious you're still learning it. That's ok.

The next key point is knowing how your current attending wants his or her presentations organized. Lots of variation here and you just have to be flexible and adapt. Ask the residents and they should be able to tell you how this particular attending wants things done.

Make sure you use clear stated markers in your presentation. "On exam....." and "my assessment is...." or "active problems are ...." or "plan by systems - for neuro, we will....". whatever it is, give people clear signposts so they know where you are going.

Make sure to use your big kid words. Don't ramble about low platelets, low white count, low crit - say "this patient has pancytopenia." Don't say he was desatting, say he has hypoxia or hypoxemia (know the difference even if it's often used incorrectly). Learning how to communicate about patients is a crucial skill that will shape how others perceive you going forward.

Finally, accept that your plans are going to have many flaws. If you were able to produce flawless assessments and plans for complex medical patients, you could just go ahead and skip the rest of training because that really is the ballgame in IM. You're not going to learn in a few weeks what your residents are spending three years to learn and your attendings have been doing for even longer. Just keep making the effort like you're doing and focus on being a little bit better each time.
 
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OP, just want to be sure in order to make sure we can give you the best advice: do you have residents on your service or is it just you and attending? I notice that you don't explicitly mention residents in either of your posts...

I know we tend to assume, but if you are a DO I guess there could be a chance it is a preceptor only based rotation

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I would add to the above that your ultimate goal in a presentation is to tell a compelling story. As such, you want to come to a point where your HPI is already laying the groundwork for your assessment. I.e., you think someone is coming in with pneumonia and chf exacerbation, you might open your presentation saying it's a 67 year old man with a history of CHF with an EF of 28% and COPD who presents with 3 days of cough, fever, and now with altered mental status, etc. As you go through the rest of it, you'd highlight other salient findings to support your assessment (though don't editorialize along the way, just give the facts). You'd be sure to mention the pitting edema, the murmur, bibasilar crackles, CXR, etc. By the time you arrive at the A&P, nobody should be surprised by what you say.

I'll add that this is a difficult skill to learn and one you will continue to perfect throughout training. I get called for consults all the time by fellow residents who wax on about completely irrelevant things and somehow stumble into their question for me, and others who give me the salient one liner, background, and a clear and decisive question I can answer. FYI I love those people because it makes my job sooooooooo much easier and I'm not chart diving trying to figure out what exactly they want me to do in the first place.
 
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You're just getting started. I'm sorry if your attending is an actual ass who is yelling at you for it, or it's possible you're not used to receiving what we call Feedback. Anyway the point of it is listen to the critique and adjust so you do better next time - that's not that you're subpar but that you're learning.
 
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Arguably the best presentation teachings I ever had came from an obgyn attending who would listen to our presentations and then present the patients back to us - complete formal presentations from start to finish, and ask us what was different about his. I seriously think I learned more about presenting in those three or four days than the rest of med school combined. Granted I spent the rest of that rotation in the hallway, but totally worth it for the few days with him.
 
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OP, just want to be sure in order to make sure we can give you the best advice: do you have residents on your service or is it just you and attending? I notice that you don't explicitly mention residents in either of your posts...

I know we tend to assume, but if you are a DO I guess there could be a chance it is a preceptor only based rotation

Sent from my Pixel XL using SDN mobile

Just me and the attending lol. The other day I told him my concerns and he was more than happy to sit down and help me. Taking all the advice you guys are telling me! thank you!
 
You're just getting started. I'm sorry if your attending is an actual ass who is yelling at you for it, or it's possible you're not used to receiving what we call Feedback. Anyway the point of it is listen to the critique and adjust so you do better next time - that's not that you're subpar but that you're learning.

Oh no, he's not an ass. There was just a misunderstanding between the two of us. We're on the same level now and he knows where I'm at. Sat down and helped me out the other day and it honestly helped a lot
 
I know we tend to assume, but if you are a DO I guess there could be a chance it is a preceptor only based rotation

Sent from my Pixel XL using SDN mobile

My MD school has OB/gyn rotations w/o residents at some hospitals. I think all IM and peds has residents though
 
I started IM this week and I've found out that I'm pretty bad at making assessments/plans. I figured I'd be decent at it at this level given my step 1 score, but apparently not lol. Got chewed out every day this week by the attending cause my A/Ps were just terrible. It was discouraging to the point that I was considering not doing IM as a residency. Is this normal for a 3rd year on his 2nd rotation of the year? Cause the attending made it seem like I should be good at this. Tips on improving? thanks

No this is NOT normal!

This attending is being unrealistic, and forgets what he was like at that stage of training.

July 3rd yr medical student should focus on a thorough H/P, getting the labs, imaging, etc...

You should absolutely formulate an A/P, the sooner you start doing this the better, but this is the hardest part. At this point in time, you havn't even been introduced to all the different services, so it is impossible to understand even the way medicine works yet. It is unreasonable to expect a July 3rd year student to formulate an effective A/P

It will get better though....
 
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