Is it normal to still feel like I don't have a clue?

[Guest ERCat]

I am coming up on two years as a PA in the ER.

Some days I fly through patients feeling comfortable about my decisions. 

Other days, especially when I am dealing with complicated patients, I become uncomfortably aware I have no idea what I am doing and have to lean on my attending heavily, probably annoying them in the process. Even if it's a complex case I have seen before... I still freeze up and forget what to do. I still need my hand held some days. 

This  is made worse by the fact that I work with over 40 different doctors and they all have different ways of handling all situations. I feel like I can never get a grasp on what I am actually supposed to do except in simple cases.

Sigh...

[JMPAC]

I just hit the 2 year mark out of school and work in the ER, too. You’re totally normal! I get more and more comfortable and confident, but still have cases or whole shifts where I feel like I’m a student again. Two years isn’t that long, if you think about it. It’s good to use your resources and keep learning. Way better than being more confident than you really should be and missing something or doing something harmful. It’s good to know your limits and just keep working towards expanding them.
I’m sure you’re doing great! Keep working hard and learning everything you can. Don’t worry about annoying your attendings, there was a time when they were the ones learning and they probably understand.

[GetMeOuttaThisMess]

Try reading Trauma Room 2 that I just finished reading as part of my Amazon Prime membership.  Lone doc in a small ED and he goes through several different patient scenarios over his career.  It is written from the perspective that you're in his head with him.  Not even for these folks do they all have the answers.  I sure didn't after my 10 years in the ED.  About the time that I thought I was really starting to get it figured out, and was becoming a little full of myself, there would always be that case that you would want to slap your forehead with your palm and go "duh".  One of the things that I believe I've finally learned is 1) don't overthink, and 2) "What's the worst thing this could be" and then work back (within reason of course).  Bottom line, don't fret.  When I went to the ED we (PA's) were new in the EDs in Dallas and I was the first at my major Dallas hospital.  The great thing was that the docs had no one to compare me with but I felt the pressure to be their equal so that I could set a good baseline to warrant bringing others in.  I guess it worked at our facility since others were later hired, and then later, when I did the same thing at a different medical system ED in the 'burbs (they already had a couple of PA's at the city mothership).

A suggestion?  I keep notes in Notes on my iPhone for those things that are infrequent though I could reasonably expect to see again.  One I hadn't heard before that I got from one of my SP's during last month's state required meeting was the acronym "SHIITTT" for sources of hematuria.  It's now in Notes.

How about everyone's favorite "SHART" for Serotonin syndrome:  

Sweating,

High body temp,

Agitation,

Rapid heart rate, and

Trouble moving

Between he and I, it's always something to do with the GI tract.

Bottom line, don't sweat it.  EM, just like any other specialty, is a learning curve, just as life itself is.  If the docs aren't grumbling then I wouldn't sweat it.  I can relate to the hundred different docs and they all want things done differently.

[sas5814]

First of all 2 years isn't enough time to really get going and feel confident particularly in ER. My opinion? 4 or 5 is more like it. Also you will be confronted by things that bamboozle you from here to eternity. I have been at this almost 30 years and I still get some presentations that totally puzzle me.

 

"This  is made worse by the fact that I work with over 40 different doctors and they all have different ways of handling all situations"

This way lies madness. If you work with physicians who want you to guess how they would handle everything and do that ...you will go mad. It is hard enough with 1 and impossible with 40. The only thing that should matter? Is course of eval and treatment you picked medically appropriate. There may be many correct ways to approach a given problem. When you reach a point where you choose a path with confidence and know you can defend it if asked you will feel much better. Give yourself enough time.

[JMPAC]

I’ve heard the 5 year mark is where most people feel reasonably comfortable, quite a few times. Looking forward to it!
I like that there will always be a case here and there that keeps you on your toes. That’s what makes medicine so interesting, I think. There’s always going to be something to learn.

[Guest ral]

If you ever get too comfortable with your knowledge and abilities, watch out; God is about to poke you in the forehead, to remind you that you are human.  Nothing wrong with critiquing oneself.  I do it frequently, and feel it keeps me in check.  When you're having one of those WTF moments with a patient or two, think about the other twenty you've already seen and treated that day, which didn't give you pause.  

[ventana]

2 years in

 

you still should feel a bit dumb at times

 

15 years in and I still have those "ugh" cases - they are just less frequent

[BruceBanner]

If you think about it physicians are 4-5 years into seeing patients by the time they get into practice. And they've been seeing high volumes, usually in academic tertiary settings.

It's ridiculous to think we should feel confident just 2 years into working. 5 years is more like it, and has been the case with me as well. But never ever ever get too comfortable. That's when you will get throttled and humiliated by something that flew under your radar.

[sk732]

Dude/ette, I've been doing this for 9 years now, and I still run into stuff I haven't seen before or something that's a weird presentation of a common thing that makes me look/feel developmentally delayed...lucky for me, some of my docs get stumped the same way and are humble enough to admit it.

SK

[muchi]

HI also coming up on two years in the ED straight out of school. Have the "im still dumb" moment at least once every shift. Think about it, our attendings were still residents during their first two years in practice, so there's no way we'll be so confident yet. I listen to EMRAP Podcasts and try to study specific diagnoses i'm uncomfortable with to get better!

[skyblu]

Yup, totally normal. It took me several years in the ED to feel somewhat competent, but I still regularly read up on unusual cases in addition to staying up to date with guidelines and recommendations.

Going on 8 years as a PA and I learn something new every day! I especially learn when I teach or precept PA students. I highly recommend doing it!

I also highly recommend the blog Academic Life in EM and a subscription to the EM:RAP podcast.


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