Anxiety about practicing... Don't feel I've studied enough.

[Guest ERCat]

I am a second year student halfway through my rotations. In six months I will my graduating and getting ready to take the PANCE. All of a sudden this major anxiety hit me -- how in the world will I be a competent provider even with an SP? I am terrified.

 

Doing a rotation in the ED right now and am shocked at how much I don't know. The nurses seem to know more than me. Today I was asked to work on a stable a-fib patient and I didn't know what to do. At all. Now when I got home and read I thought "Hey, this is familiar, I knew this." But that is how all of my knowledge seems to be. I don't know what I need to know at the top of my head, confidently. I seem to look everything up and even then sometimes I am totally floundering.

 

To be totally honest I have not put in the dedicated study I need to for PA school. First semester I did study my butt off, but the second and third semesters were easier so most of the time I just studied for exams as they came up. There were many days I would just come home after school and watch TV if there wasn't a test that week. Makes me cringe just thinking about it. Even in the first half of my rotations I studied sporadically, too. I read some different things online about PA students not having a life and that's not me at all. I have had plenty of relaxing days in my PA education.

 

Now I am scared out of my mind. I am not even worried about the PANCE... To me that's just a test. I have scored at national average on the PACKRAT and have done slightly above the class average for a lot of my program's exams. I am worried about how I am going to perform in the real world and how I am going to take care of my patients properly. I can't explain it but I have a sick feeling in my stomach and am disappointed in myself. I don't know why it's only now that I am wanting to take studying seriously... I am ready to REALLY work my butt off (not just kinda work my butt off) but I worry it is too late to get prepared for practice by the end of the year.

 

Just wanted to see if any of you had a similar experience or could offer me any words of wisdom and encouragement. I could really use it right now.

[EMEDPA]

pick up some high-yield study guides for each rotation from here on out and read them cover to cover.

For EM start with

1. minor emergencies: splinters to fractures http://www.barnesandnoble.com/w/minor-emergencies-philip-buttaravoli/1100574757?ean=9780323007566

2. Emergency medicine secrets.http://www.barnesandnoble.com/w/emergency-medicine-secrets-vincent-j-markovchick/1100251386?ean=9780323071673

3. emergency medicine manual http://www.barnesandnoble.com/w/emergency-medicine-manual-o-john-ma/1100151995?ean=9780071736022

[Guest ERCat]

Thank you.

[taotaox1]

Guilt and self-flagellation are counter productive.   Consider yourself blessed you figured this out now, instead of when you start your first job.  Study your ass off.   EMED is right on.  You should go through at least one-two high yield guide per rotation, length dependent.   Not to mention be reading between each patient when you can.

[UGoLong]

Unlike in school, in clinicals and in your job you learn as you go. You will be stumped from time to time, either because you are seeing something new or because some isolated facts you once knew have been forgotten. Don't beat yourself up; get help when you need it and go home that night and review what you've seen. That's where the lifelong learning part comes in.

 

That you CARE that you didn't know something is a great start; don't use it as a whip to beat yourself up, but rather an incentive to learn more and become more competent.

 

Good luck.

[LoRezSkyline]

"Blueprints..." series for whichever rotation you're on along with "Case Files" are the most digestible, to-the-point resources I could suggest as they're generally 150-200 page or so paperbacks.  Share/rotate with classmates so you don't have to buy books for every rotation.  You can delve into deeper resources to look up specific info when you need it, but in a month all you have time for is a broad overview, hit the high points on your rotation objectives and the PANCE Blueprint.  If you need practice prepping for your end-of-rotation exams, "PreTest" usually is a good start as they're straight MCQ with explanations as to why answers are or aren't correct.  

 

You do need to buckle down and get serious, but the fact that you seem to have some self-awareness of your limitations is a good thing - my classmates who didn't take things seriously, never expressed a smidge of fear or awareness of their incompetence while we were in school are the ones I wouldn't want taking care of me or my family...

[gbrothers98]

You have been given much great direction in terms of resources to use to improve your perceived deficits.

I cant argue with any of that, I have used all of them at one time or another and they have the information you need.

I am going to offer some counterpoints though and also offer up some questions to reflect upon.

 

But first, everyone has doubts along the way. I graduated with honors from my program, did very well in clinical year and felt very comfortable in my role. Then I started working and the self doubt and anxiety creeped in. With time and experience, this went away near completely but most clinicians always harbor some self doubt about certain cases and instances. They just manage it better.

 

Concerning working harder. We all have an assumption that hard work will get us places. But it is only part of the solution. You successfully moved on to clinical year and you scored well on testing. You had to do some work to get there even if you took some time to watch TV. In fact watching some TV may have actually helped. There are plenty of cognitive psych studies concerning learning that tell us the opposite of what we thought always worked. You actually need sleep, all nighters screw you concerning information retrieval and retention. Spaced exposure to material actually helps rather than massed practice, which is what many students do. So going to lecture, going home and doing something mindless and then revisiting material later actually works. It also seems like you struck a balance vs the usual PA student whom successfully gains 30 lbs, alienates friends and family and develops a whopping case of anxiety and gerd didactic year. Last, would any of that harder work actually have gotten you anywhere in comparison? You likely have witnessed your overachieving classmates whom expended much more effort to only end up just slightly ahead of where you landed. 

 

Here is the insight to be gained about PA school. The first year is mainly information delivery. Have you heard of Blooms Taxonomy in education? It is a pyramid of learning stages, the higher a student progresses, the more substantial and complicated learning is. At the base is understanding and remembering. This is the bulk of didactic year. The next step is applying which you start doing didactic year and continue during clinical year. The top of the pyramid consists of creating, evaluating and analyzing. This is what clinical year is all about.

 

It is the most difficult thing you will have to do because quite frankly, most students have not been pushed to that level in the past. They also have not observed the process on a regular basis. My experience as a military medic was invaluable because I was able to daily observe the physicians and PAs I worked with do this. But observation only gets one so far.

 

So that brings us to your atrial fibrillation case. You are at a loss of what to do. You go home later, read up on things, do some self flagellation and write your post. Here is the question. What is your role? Is your responsibility to manage that patient from start to finish without a hitch? Or is your role to learn from that experience for future encounters? Or to be faced with a test question concerning afib and answer correctly based upon your hard won experience?

 

What causes student angst and anxiety is that they think they have to always know the correct answer and that they always have to do everything right the first time. Save that for the working world, you will be there soon enough. But in the meantime, dont get lost in self doubt because you are in a learning process you have no experience with before. Focus on that process. When you dont know what to do, what you do know is where to get answers. That is not running to the attending or a preceptor but take ownership and find that solution in the resources you have been directed to. You will remember those answers for the rest of your life.

 

I have a conversation with students frequently. You will see 3 types of patients. Health care maintenance ie well child, pap smears, yearly physical. There can be very little exercising of clinical judgement with these at times. Next is management of chronic disease. More clinical judgement but until the comorbidities start piling up, these can be rather straight forward. Finally, the acute complaint, which can be new or an exacerbation of chronic disease. That is where you do your work at the pinnacle of the pyramid I described before. 

 

To be successful there requires much more work with the last patient class than the first 2. That is where you find yourself with the afib patient. I am assuming this will be the first afib patient you have ever managed? And your rationale that you would do and know everything stems from what? 

 

The only way to get better at those patients is to do two things. First understand that the patient came with a complaint and symptoms. They likely did not announce they had afib at triage. Start looking at disease from a symptom perspective. This was something I personally did to be successful and it is particularly important to do in settings such as the ED. Second, a clinician just needs experience with patients. You get that during clinical year and further experience will come in your career. Every patient you see enables you to build illness scripts. Illness scripts are a schema of knowledge based upon self experience concerning a specific disease process that a clinician can utilize for similar future patient encounters. Gaining this experience in a structured learning environment vs in the workplace is why PA residencies and fellowships are becoming more popular. Keep that open as an option for your career. It is an invaluable professional experience. If physicians have to move through 3-5 years of that experience, why would it not be reasonable to afford PAs the same, if shortened to a year?

 

Finally, you are correct. The ED nurses are smarter than you. But comparing yourself to the nurses is more unnecessary self flagellation. At a point in the future, you will have to provide those nurses with direction and orders that they will have to place their faith in that you know what you are doing. Recognize you will have to lead the same people in the future. In the meantime realize that they want you to be successful and can be your greatest asset. So throw them some sugar, thank them for their help and buy them donuts during the rotation, not at the end.

 

Good luck

G Brothers PA-C

[whoRyou]

^^^Thank you for your feedback Mr. Brothers!!!  

[Guest ERCat]

Thank you for your feedback. You guys are all the greatest! You gave me a new perspective. No sense in beating myself up, and maybe I am not giving myself enough credit.

 

I've realized that one of my biggest problems is reading things more in depth than I need to. I am NOT a quick studier. If I study a-fib, for example, I will read Uptodate, Current Diagnosis and Treatment, my class notes, and a quick study guide on the topic. Then I start freaking out when I see other things I don't know well and then I will read about that. Instead of getting the main important points about a-fib and having a "plan of attack" in my mind (i.e. the basics about how it presents, how it is diagnosed, how it is treated, what to watch out for, etc.) I end up having a bunch of random, disorganized, jumbled facts in my head that I can't apply to practice (and since I can't apply it I will forget it). I think I realize I need to stop getting bogged down in the details. I need to be okay with reviewing a topic for a bit and moving on to another.

[EMEDPA]

just remember not everyone with afib needs coumadin.

learn about chads scores:

http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/

 

md calc by the way is a great site to bookmark for other tools like perc criteria for PE, etc

[whoRyou]

Thank you for your feedback. You guys are all the greatest! You gave me a new perspective. No sense in beating myself up, and maybe I am not giving myself enough credit.

 

I've realized that one of my biggest problems is reading things more in depth than I need to. I am NOT a quick studier. If I study a-fib, for example, I will read Uptodate, Current Diagnosis and Treatment, my class notes, and a quick study guide on the topic. Then I start freaking out when I see other things I don't know well and then I will read about that. Instead of getting the main important points about a-fib and having a "plan of attack" in my mind (i.e. the basics about how it presents, how it is diagnosed, how it is treated, what to watch out for, etc.) I end up having a bunch of random, disorganized, jumbled facts in my head that I can't apply to practice (and since I can't apply it I will forget it). I think I realize I need to stop getting bogged down in the details. I need to be okay with reviewing a topic for a bit and moving on to another.

I tend do the same thing. From what others have told me is just pick 2 or 3 sources to study from and no more so you don't get overwhelmed. You need to trust yourself that you know what you know and obviously practice and then go for it 

[SocialMedicine]

you will still be shocked at how little you know 6 months after school ... and probably 2 years after as well. You finished PA school  not an MD program and 4 years residency. You will be expected to continue learning at an aggressive pace for years. You will need to work a few hours after "work" each week in order to become good. if you do not you can do flu shots at the elks lodge, Keep working hard. Recognition of knowledge lapse and acting on it is a major plus for you. 

[rpackelly]

Basically, if you do not have butterflies in your stomach, you should not be practicing.  Lack of anxiety is a bigger concern than anxiety.   But study at least one hour per day on things you have seen that day and keep that up through your career.  When you are a student, add 8-12 hours a week on the days you are not on rotation.  You will be fine. 

[LESH]

old reference but I'm old....

[tariesen]

Great wisdom in these posts - thank you. We start rotations in early June and already the self-doubt is creeping in. I'm excited and terrified at the same time! I remember reading somewhere on the forum to have an accessible stack of "flashcards" with the most common diseases, etc. and their S/S, Dx method, and treatment options. Probably wouldn't hurt to start working on that stack now... 

[Maverick87]

I suggest purchasing Up To Date.

 

That site saved me in my first few years practicing multiple times.

 

It's a little pricey ($500 a year I think), but it's worth it and you could accomplish most of your CME credits on there (I completed all of it from there, but I am one of the last ones on the 6 year cycle for re-certification....the 10 year cycle requires a bit more than simple CME).

[tariesen]

Thanks, Maverick! I'll have to look into that! :)

[cinntsp]

I suggest purchasing Up To Date.

 

That site saved me in my first few years practicing multiple times.

 

It's a little pricey ($500 a year I think), but it's worth it and you could accomplish most of your CME credits on there (I completed all of it from there, but I am one of the last ones on the 6 year cycle for re-certification....the 10 year cycle requires a bit more than simple CME).

 

It's $99/yr for students and $399/yr for PAs through AAPA's member discounts just as an fyi to everyone.

[Torshi]

do a residency after u graduate

[EMEDPA]

agree with Torshi. this is the best thing you could do to set your career on a strong path for the future.

[jtmathew]

just remember not everyone with afib needs coumadin.

learn about chads scores:

http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/

 

md calc by the way is a great site to bookmark for other tools like perc criteria for PE, etc

I think chads score needs a "likelyhood of compliance" button as well.

I havent started my program yet but some things that come to mind when treating a-fib :

anticoagulate (if candidate, i feel like most patients will, at least, get aspirin)

medicate (positive/negative inotropic)

ablate (if age appropriate)

Am i missing anything?

[fireguy]

It took me about three years of full time ER practice before I felt comfortable with my knowledge base, and I had 20 years of paramedic work prior to PA school.  To be a seasoned practitioner, you have to go through e seasoning...  keep reading, don't be afraid to ask questions and keep pushing forward.