I’m very overwhelmed on my first rotation (FM) and I’m really worried that I’m just not cutout for this. Does it ever get better?

[Latteandaprayer]

TL;DR-I’m overwhelmed on my first rotation and I want to know if things improve. The worst is that I don’t have much time to read about patients and think about diagnosis and treatment. You can honestly skip the rest lol

Our school is 1 year preclinicals, so I’m an M2 two weeks into my first rotation of family medicine, which ends in 2 weeks. I get lukewarm feedback from my preceptors at best. Some say “yeah you’re fine” or “I think you’re meeting expectations,” while others are like “you need to keep reading” and “you need to get better at knowing the patients.”

It’s been hard because most patients are like 50+ with a lot of past history, and some specialists on their cases, and I’m given like 5 minutes to prep for each patient beforehand. Every patient of course comes in with a few concerns on top of their HME. I never see the same problem twice except like diabetes.

The worst part is my assessment and plan. I honestly don’t know anything. I don’t know common from uncommon conditions and their presentations. I had a 1 year old come in and his mom said he’s always thirsty and pees a lot. I told my preceptor I’m worried about maybe T1D. He looked at me like I was crazy and said “no I think he’s just a growing boy.” I don’t know how to treat a lot of things. NSAIDs and ice or an X ray and brace? I don’t know. The issue is because it’s outpatient, I need to come to a diagnosis and provide a solution in 20 minutes or less, and the doctors don’t give me time to digest and look up some info. I know it’s because they’re doubly constrained for time, it’s *my* failing.

I’m trying case files and uworld, but of course almost nothing is textbook.

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[Rapsidy]

Does your school give you access to uptodate? I’m only a M2 and we don’t start clinicals until M3, but I’ve heard many M3’s and M4’s swear by using uptodate to sneak a peak between presenting or before seeing a patient to help with the assessments/plan. Just checked myself but you can log in through your institution on their app so you can take that quick peek without needing a laptop.

Also do you have a copy of pocket medicine? Also heard it’s a great source to peak to if you feel lost or confused.

 

[Goro]

Sounds like you're right on schedule. You'll be fine.

 

[Dral]

You’ll get better. For the T1D thing, you learn to ask f/u, “is this new or has it been like that for his life?” If parent says not a new sudden change, you report to preceptor, “I thought about DM, but the drinking a lot is not new and baby is 80th %tile weight so I favor just normal”.

You’re starting in the “learning from experience” part of your education. Objective facts help, but you have to just literally experience things to learn as well.

FM and probably surgery are the two difficult first rotations. Just study a lot and keep going. You’ll be better set up for your IM rotation because of this.

 

[Latteandaprayer]

Does your school give you access to uptodate? I’m only a M2 and we don’t start clinicals until M3, but I’ve heard many M3’s and M4’s swear by using uptodate to sneak a peak between presenting or before seeing a patient to help with the assessments/plan. Just checked myself but you can log in through your institution on their app so you can take that quick peek without needing a laptop.

Also do you have a copy of pocket medicine? Also heard it’s a great source to peak to if you feel lost or confused.

Yes, but the issue I’m running into is no time. Whenever I do have time I look it up, but i honestly rarely have time.

ETA: at the point of the appointment, not in general of course. I go home and read about what I saw and any questions I have, on top of studying in general.

 

[deleted1079620]

Your job as an M-2 is to be a good record keeper. Clinical decision making skills will come as you progress in your education, so give yourself some grace. For now, focus your time & energy on taking a good HPI & writing good notes, and keeping yourself organized during presenting. And keep reading!

 

[LunaOri]

Of course you don’t know anything! You just started! You are exactly where you should be, and recognizing what you don’t know is the absolute most important thing to have learned at this stage. Much better to know that you don’t know than to think that you know it all. Confidence will come with time. Family med can be a hard rotation to start with because there are so many possible diagnoses. Just try to read up on one condition per day. And by the way, DM (or DI) can present with excessive drinking and peeing, so DM wasn’t a bad thought, even if it wasn’t the correct diagnosis.

 

[operaman]

Yup. You’re exactly where you are supposed to be. Just keep working at it and get better every day. Every student is terrible in the beginning; that’s why we don’t let them see and treat patients unsupervised. The good ones get a little better each time. Take the feedback and keep working at it.

Remember that you have a minimum of 5 years before anyone let’s you put to treat patients on your own. You’re maybe 6 weeks in. It’s a marathon, not a sprint.

And Try and remember how you feel now when you’re on the other side.

 

[redalert]

Presenting patients takes practice, particularly you need to know the soap format cold (or whichever format your school uses). If you can get the summary statement, objective data, and problem list down for each patient then most of the battle has been won. No one expects you to have a perfect A/P as an M2 everytime but if you can demonstrate your thinking process and sound intelligent when presenting, I guarantee you'll get great evals.

Don't get bogged down on the chronic problems too much, focus on the acute issue and the relevant history. For example, for a patient coming in for back pain you need to know if there's any trauma, activities, prior imaging and intervention. But things like htn and t2dm likely won't matter much and you won't change their management anyway.

Honestly in clinical years I felt like I was just putting on a show, trying to impress attendings my presentation. By the end of your M2 year hopefully the soap format will become second nature and you can actually think about patients issues.

 

[butidontwantto]

If you have access and are allowed to rummage through the EHR, maybe take some time at the end of the day to see what’s coming the next day. So like, if someone is coming in for something you don’t feel solid on you can read about it the night before. Even if all you get is reason for visit, that can be helpful, e.g. all it says is palpitations, so look up what’re some things on the differential for palpitations? What are some things you could ask or tests you can run to suss out what’s going on? If it makes you feel any better, even after scribing for a long time in a family med office, I still felt like an idiot most of the time during my fm rotation. There’s just so much fm docs manage. The jump from recognition to recall is a tough one to make too as you move from preclinical to clinical. I can’t tell you how many times I’d get pimped on something and could see the sketchy and still not find the answer in my brain lol.

 

[esob]

Yeah, you're fine really. It feels overwhelming at first for most people unless you've had prior medical experience. It can still be overwhelming even if you have had that prior experience.

As mentioned above, uptodate is your go-to. If you don't have access to uptodate, the next best thing is probably visual DX, which is like $75 a yr for medical students. Just remember to set the agenda when you get in the room. "Hi, Mr. Smith, I'm Terry, a 2nd-year medical student. I'd like to talk about the number one thing that brought you in to see us today." Otherwise, you will have a bunch of patients that wait until they turn 65 and get medicare to come to see a doctor for the first time in 30 years, and you aren't going to get through all of their issues in 15 minutes.

The other caveat is to ensure the patient isn't critically ill before doing anything. You'd be surprised how many people will make it past check-in and screening before finally admitting to the medical student that they're having radiating chest pain but didn't want to worry anyone

 

[operaman]

Yeah, you're fine really. It feels overwhelming at first for most people unless you've had prior medical experience. It can still be overwhelming even if you have had that prior experience.

As mentioned above, uptodate is your go-to. If you don't have access to uptodate, the next best thing is probably visual DX, which is like $75 a yr for medical students. Just remember to set the agenda when you get in the room. "Hi, Mr. Smith, I'm Terry, a 2nd-year medical student. I'd like to talk about the number one thing that brought you in to see us today." Otherwise, you will have a bunch of patients that wait until they turn 65 and get medicare to come to see a doctor for the first time in 30 years, and you aren't going to get through all of their issues in 15 minutes.

The other caveat is to ensure the patient isn't critically ill before doing anything. You'd be surprised how many people will make it past check-in and screening before finally admitting to the medical student that they're having radiating chest pain but didn't want to worry anyone

Love this.

I feel like preclinical teaches you a lot of good stuff re clinical encounters, but also a lot of things that are woefully impractical. Like they all teach to let patients talk and don’t interrupt them - great if you have an hour, but a total waste of time otherwise. Setting the agenda is key.

My FM preceptor would solicit a list of complaints and stop them immediately after they stated one and ask, “ok what else?” And repeat until he had a list of their concerns. Then he’d ask them to pick their most concerning one and he would pick his most concerning one and then focus questions on those two. Of course he had been practicing FM for 25 years so he had it down to an art form and patients loved him.

OP- another thing to remember is that FM is one of the hardest rotations in terms of sheer breadth of knowledge. It’s very tough to start on from this perspective because you really do need to know a little bit of everything.

The other tip I was given early on was to weight your reading by incidence of the condition. So for FM, make sure you know HTN, DM, CAD, and similar things really well. Make a list by system of the 2 most common issues in each system you see in FM and know those really really well. Broken down that way it’s a far more manageable amount of info and prepares you for a huge chunk of your every day.

Lather rinse repeat for whatever rotation you’re on. I’m ent and if you were rotating with me, you’d want to know chronic sinusitis and allergic rhinitis absolutely cold. Hearing loss, adult neck mass, hoarseness - also good things to know. There’s plenty of other things to know, but those alone would carry you through a lot of encounters and make it easier to read about patient specific issues that come up.

 

[TelemarketingEnigma]

but I’ve heard many M3’s and M4’s swear by using uptodate to sneak a peak between presenting or before seeing a patient to help with the assessments/plan.

pssst... your residents (and even sometimes attendings) are often doing this too

Yes, but the issue I’m running into is no time. Whenever I do have time I look it up, but i honestly rarely have time.

ETA: at the point of the appointment, not in general of course. I go home and read about what I saw and any questions I have, on top of studying in general.

make sure you have the uptodate app on your phone! quick peeks on your way in and out of the room can be surprisingly helpful

I think uptodate gets easier to use the more experience you have and the more you start to develop your gut diagnostic chops, which comes with time and is very hard on the first rotation! You'll get better at knowing where to look for the info you need since most articles share a very similar format - if you want to know what tests to do, that'll be in the "diagnosis" section/article. If you know the diagnosis already and just need to decide therapy, there's a "treatment" section for that. save reading the whole article for later, for your own learning.

(you also eventually learn when NOT to use uptodate, and where its limitations lie)

 

[Splenda88]

You would not need 2-3 yrs of clerkship and 3-7 years residency if you knew everything day1 of your clerkship... Things will get better.

 

[dienekes88]

In a word. Yes.

I remember getting confused about just the rotation requirements during my first clerkship. I fell flat on my face the first time I presented on rounds.

It happens again. And again. And again. Because that's how you grow. And if it doesn't happen... then you may be doing it wrong. If you don't push yourself to be uncomfortable, you're never going to get better.

 

[PeteytheFish]

My first rotation was surgery, and it would be fair to say that it did not go well. One week in, I absolutely sobbed in front of the course director because I felt so overwhelmed and lost. He helped me out a lot by explaining this to me: As medical students, we are not supposed to know what is going on right from the beginning. If we knew everything, we wouldn't need to be here. Our preceptors and course directors fundamentally know that we are "dumb" (he made sure to emphasize that he didn't mean stupid or untalented, but green). Our only job is to show up and be just very slightly less dumb the next day, and ever so slightly less dumb the next day. Eventually, these incremental changes will add up and we will start looking and feeling more confident.

Me? I feel like a dumba** 90% of the time, but I ask lots of questions, demonstrate knowledge when I can, look stuff up, show that I am interested (this part is KEY), and generally treat every day like a new learning experience. Some days it feels great. Other days I leave feeling pretty low. But you know what? I'm five rotations in and it's true: even though to a degree one has to start from scratch on every rotation, I can see the progress that I have made.

Keep your chin up. Medical school sucks and is a constant body blow to the ego. But you are NOT alone. I guarantee you that most of your classmates are feeling the same way, even if they aren't talking about it.

This path we've chosen takes 7+ years for a reason. It's not easy. You won't get it in a day. But you WILL get there. Hang in there.