congratulations! You’ve graduated medical school…and MATCHED into a Family Medicine Residency Program. You made it! You’ve worked hard, taken your exams and broken your booty to get to where you are now.✓
You can now introduce yourself to patients as DOCTORS! That proud moment you’ve been waiting for. BUT then…your body begins to feel like it doesn’t belong. Your mind tricks you into thinking, “there is no way I’m a doctor”, “I don’t know what I’m doing”, “How can I possibly call myself a doctor”.
This is all normal. Imposter Syndrome is a real thing. It comes hard and stays for a while. Cling to it… it will push you to read more, pay more attention, listen harder and remember.✓ It will force you to become better. So why do we all feel this way?
Because We’re Not Wrong.
Let Me Explain.
When I think of the life cycle of a medical professional, I very much believe it is like that of a frog.🐸
- Undergrad = eggs.
- Medical student = embryo.
- Intern = tadpole. 2ndyear resident = tadpole with hind legs.
- 3rdyear resident = look like adult frogs but still have a small tail
- Attending = frog.🐸
All Interns are tadpoles.✔️ No legs, still growing. Not ready but on their way. That’s right. I myself am a tadpole, but I’m about to sprout my hind legs soon! It’s just a few months away.🐸
So naturally, you don’t feel ready. Yet, you are. Intern year is a combination of 3rdand 4thyear of medical school on steroids and then throw in a major splash of responsibility.✓ Each patient is yours, their outcomes are yours. It becomes your responsibility to care for them. Has the fear set in? Good. And now let me reassure you. Although you are thrown in headfirst without the least idea of what to do…there is a massive safety net underneath you ready to catch you if you fall. Although you are making every medical decision, you have guidance if you don’t know what to do. The key is to recognize when you don’t know what you are doing.🐸
Believing you know more than you do, is more dangerous than admitting you don’t. Your attendings will fill in the gaps in care, add things, take things off, increase or decrease meds, or doses and add diagnosis you missed or just alter it a bit. These patients are yours, but they are also your attending’s, but don’t let that make you lazy now.
Family Medicine has the beauty of being all-encompassing, as you already know. “From cradle to grave,” we say. And although it’s beautiful that we have the opportunity to care for men and women, young and old, pregnant and just born; it means we need to know about everything. So it can be intimidating, especially when you start seeing patients in the clinic on your own.
From day 1, you see your own patients in the clinic. You start with 2 a day, and gradually increase the numbers you see. This will help you not only get the hang of clinic flow, but find your rhythm, learn time management skills, and realize how difficult it is to see a patient, examine, diagnose, treat and counsel in only 15-30 minutes. But you will get here I promise! I am already seeing 5-6 patients and honestly….I took much longer when I only had 2 HA!.
Let’s not forget that although family medicine has all the above mentioned, we also focus on preventive services. This includes colonoscopies, mammograms, pap smears, AAA screening, Hep C screening, diabetes screening, depression screening, alcohol use screening, smoking, flu shot, pneumococcal vaccine, and beyond…and eventually maybe coronavirus vaccine too. It can be difficult to discuss every one of these items in one visit and it’s not because of the time constraints. It’s because they should all occur in different age ranges, different demographics, earlier for special reasons or not at all because of age. And, you must access these things all AT THE SAME TIME to allow your clinic to flow. It takes PRACTICE! You will eventually get the hang of it.
One tip I have learned from my attendings is, “don’t wait for tomorrow what can be done today”. This means, even if they are there for a sick visit, mention these screening tests and offer referrals so they can get up to date, schedule return to the clinic (RTC) visits for procedures, etc.
Think ahead. Keep your patient’s health up to date.✓
It is not their job to know what they should be getting done, although it would help if they did. It is YOUR job to know and to offer it at every visit even if it declines every time. And don’t forget to DOCUMENT the offer and the fact that they declined it every single time.
Also, learn your coding. Huh? Each clinic visit needs a code. It is how patients are charged so that your clinic can bring in the $. New patients and established patients get different codes. Well-child visits get different codes. Procedures have different codes. And then there are modifier codes that show you did something additional that is not covered in the first code. It can be daunting. But you will get it, I promise. Ask your upper levels for guidance, or your attendings.
The last thing about the clinic is this: it feels as though you are out there on your own. It is scary to be responsible for a patient.
- What if you forget to mention something that is important?
- Or if you forget to ask a pertinent question?
- What if you forget to talk about a screening test? Etc.
Your mind will race. Luckily, every patient encounter you have must be discussed with an attending. So here are tips on what to do PRIOR to discussing the case with your attendings.
- Create an Assessment and Plan including differentials✔️
- Read up on those ddx✔️
- Practice your case presentation✔️
- Remember to mention ONLY pertinent positives or negatives (this may take practice)✔️
- Don’t feel bad if they correct you, or ask you a question you don’t know, or completely miss a diagnosis or treatment.✔️
5. is probably one of the most important tips here. Why? Simple. That is why you’re in residency. To learn the art of medicine. To put into practice everything you’ve been reading. If you could practice at the level of an attending right out of medical school, then what is the point of residency? So let your upper levels and attendings show you your gaps in knowledge. And then….fill them! This is how it has worked for centuries, and it is how it will continue to work centuries after we’re all done.
But family medicine is NOT just outpatient clinics including sports med, pediatrics, your own family med clinic, etc. It is also, hospital medicine. Including ICU, Inpatient Medicine, and ER. Let’s not forget general surgery and OBGYN. There are other things too, but these are basically it for the first year. Each program is different as to which rotations you will do in your first year, so make sure to review that.
Hospital rotations are scary. My first rotation was ICU and I will admit I was terrified. I have written another blog post on How to Survive ICU which some of you might want to read. But in general, hospital medicine has its own finesse too. ICU and adult med to me are a bit similar. ICU is adult med with ventilators, pressors, and higher acuity. Regardless of which hospital rotation you have, befriend the nurses and get them on your side. They were there before you and will be there after you leave. We are passing through. They are proud of what they do, and you will need them….TRUST ME. Also, they are with your patients longer than you are, so if they tell you something is up….believe them! Go check on the patient and assess, don’t just bark orders over a phone. Be the doctor.
UpToDate is your best friend…your partner in crime…your go-to. At least it is mine. If there is something you don’t know, research it before you bring it up to the attending. Just in case they ask you something about it you will be better equipped to answer. It doesn’t mean try to know it all. It means read about your patients and their conditions. Show interest and take initiative. Don’t just expect to be spoon-fed information from your upper levels or attendings. Do your part, and let them complement what you already have.
if you did not do it, do not say you did. If they ask you about bowel sounds but you didn’t listen, don’t say “normal”.✓
Admit that you didn’t do it. Honesty is the best policy. Not just because it makes you honest and trustworthy, but more importantly….it makes it safe medicine, it protects the patient. If the chart says “heart murmur” but you don’t hear one… admit that you didn’t hear one. If you do hear one but you’re not confident… say that. When in doubt…ASK. Never assume anything about anything. Be as transparent with your attendings as you can. Recognizing and knowing your own shortcomings as a physician will be the best tool you will have to protect your patients. It also allows your attendings to trust you and your clinical judgment. They will be able to trust that if you’re not sure of what you’re doing you will ask for help and guidance. This ensures patient safety.
Imagine if you had a family member who always tried to fix your TV, never asked for help.. always said they knew how, and every time they ruined it more. Would you want this person working on your TV ever again? Would you trust them around other electronics? NOPE
Be honest about the things you don’t know, ask for help…and then….read about it! This is what residency is about.✓
Back to the clinic: In my program, at around 6 months our clinic responsibilities change. When at first we had to discuss every single patient encounter with attendings, we now only need to discuss higher codes or patients that require more extensive medical decision making. Anything below that, we CAN manage on our own. BUT… if I have a question about something… I still ask.
Overall, the first year of family medicine is full of many emotions and thoughts. I am sure second year will be the same. The point of residency will be to manage patients on your own properly, without missing anything, and doing it with evidence-based medicine. That way, when you are working at an attending level, you thrive and so do your patients. So let residency do its job.
- 1 – Work hard
- 2 – Read as much as you can.
- 3 – Sleep when you can.
- 4 – Eat when you can.
- 5 – Admit to your shortcomings in knowledge and fix them.
- 6 – Ask for help when you need it, or if you’re just not sure about something.
- 7 – Learn from your mistakes
- 8 – Enjoy the journey
I’m already almost 1 year in, and I cannot believe how fast time has flown by. Cheers to being a tadpole!