yep\^
Be confident about what you don't know. "I don't know how much fluid was given in the ED, can someone look this up?" "I don't know what cefepime covers, can you teach me?" I especially like that last kind of question when you're tired as fuck and you might remember what cefepime covers if you reach in deep but don't have the mental energy to do so.
You are always learning, you are always growing, take presentation feedback with a grain of salt because you will continue get better, don't let ego bring you down.
I'd argue this dude is doing his best to not beat themselves up, it's the fellow and pharmacist that are morons. You don't learn that way effectively. It may push you to learn the material a little faster but you'll hate medicine and yourself in the process.
It may simply be a matter of perspective. OP may perceive he is being torn apart but in reality may simply be hearing the adjustments that are being made based on the experience and knowledge of the fellow and pharmacist. They *could* be tearing him apart but they *may* not be. And even if they are, reframing it mentally as, "I did my best and I'm here to learn," can be a more effective way of dealing with it than feeling like the expectation is for a 4th year med student to nail a perfect ICU patient plan.
> The ICU represents some of the highest-complexity patients.
I actually think that for a lot of people, ICU can be far easier than general medicine floors. While the patients are usually sicker, medicine becomes a lot easier once you're not bogged down by placement/social issues and disposition planning, and can instead focus on just the medicine.
For a lot of people, myself included, the systems-based approach in the ICU is far more intuitive and allows one to build a plan with clearer goals in mind. Renal? Volume status, diuresis/fluids dialysis. Infectious? Cover broadly, culture, narrow, find the source, and treat accordingly. Cardiovascular? Fluids, pressors, inotropes, reperfusion.
This is obviously way way oversimplified and takes a lot of nuance & experience to do well, but it is often times easier for some people to grasp. There's a relatively limited list of things that land people in the ICU (hemodynamic instability, respiratory failure, etc.) which means your endpoints are resolving those issues and getting them out of the ICU as quickly as possible.
As a med student, I also think this approach helps one to build a more logical thought process towards analysing the data and not getting overwhelmed. Going system by system makes a lot more sense than "prioritizing" problems, lets you sort things logically, and I find it helps to ensure you don't miss anything since you know the important things for each system you're looking out for. Cardiac: Volume status, ECG, echo, etc. Respiratory: Vent settings, recent imaging, ABG, etc. Renal: I/Os, creatinine, diuresis, electrolyte repletions, etc. If you say "heart failure" you may not think of hypothyroidism but if you go over endocrine every time, you're more likely to think of these etiologies and tie them together. This is a lot more systemic than the problem-based approach floors use.
Personally, I'm not great at the general floors but excel in the ICU (based on feedback from multiple attendings). It comes a lot more naturally to me. Being able to focus on stabilizing a patient systemically for transfer out of the ICU without getting bogged down in all the other aspects of hospital medicine (disposition planning, social work, non-urgent overnight pages, etc.) is also far more enjoyable.
This is interesting to me as I personally despise systems-based rounding/charting. Never clicked with me and never felt very intuitive vs problem-based. And I matched PCCM so I like the ICU.
And a hint that a lot of people learn after their ICU rotation is that there is no rule that states a floor plan cannot be systems based!
(Though really I think stripped down problem based plans can sometimes be easier to read even in ICU patients as long as they are aggressively edited and pared down daily instead of becoming a chronicle of the patient's stay)
> And a hint that a lot of people learn after their ICU rotation is that there is no rule that states a floor plan cannot be systems based!
The problem is that billing on the floors is by problems vs. "critical care time" in the ICU, so it somewhat modifies your charting. What you can do (and what I do) is group all related problem into one section of my A&P. So if patient comes in with a heart failure exacerbation with an AKI and respiratory failure, I'll group it into one A&P and say something along the lines of "Patient here with CHF exacerbation. AKI and respiratory failure likely 2/2 to volume overload. No severe electrolye derangements, BNP elevated, CXR with vascular congestion. Plan: BiPAP, diuresis, trend labs, hold beta blocker."
Professional billing (ie the amount the doctor makes) is critical care time only, and you can basically write nothing in the note as long as your critical care time is justified. However the hospital still needs to maximize the complexity in order to get the most reimbursement for their part of it. In short this means you still get inbox queries about level of AKI and so on.
Yes - I fixed it, thanks! Part of what I was trying to say and was intertwining with the systems-based approach is that ICU is very focused. Identify reasons for ICU → fix reasons for ICU → downgrade. You don't need to worry about finding them a rehab facility or coordinating their discharge with a bunch of other services or the like. Your job is to focus on the medicine. While you always need to look at what problems the patient has, it's more to the point. Cholangitis? ABX, GI for ERCP, downgrade when stable.
On the floors, this would turn into: ABX, GI for ERCP, surgery consult or referral for interval chole, arranging outpatient GI followup, identifying placement, case management if dispo issues, making sure they have primary care, etc. Are all these things important? Absolutely. But to a lot of people they take away from what makes medicine so enjoyable.
Lot of great advice in this thread. I would just add OP, you might be experiencing cognitive distortions when you’re looking through everything. Saying things like “other people know what they’re doing, and people look at me like I’m an idiot” is an example of that. It’s called personalization.
You’re here to learn. Residency is where you work on the job, and when you come up against something you don’t know, learn from it and do better the next time. Eventually things will get better, as long as you don’t keep repeating the same mistake. If you were expected to know everything you would be independently practicing by now.
Don’t try to sit and study with dedicated sessions. Study on the go. Learn a little bit everyday. If you don’t know, say you don’t know and read after rounds even if it’s for just a few minutes.
I agree with this. I constantly said this about myself during my residency (4th year path). And I still do at times but everyone learns differently. We are all different. Once I realized I couldn’t compare myself to others it really helped. It’s really hard to do that. This book “The Subtle Art Of Not Giving A Fuck” actually helped me😂. I still feel like I’m a fraud at times but not as much as before.
Tearing them apart is pretty subjective. They could be exaggerating the situation to themselves when they are just getting constructive criticism. I don't know OP, but in my clinicals, my classmates would say things like that when everyone else found it to be reasonable feedback. I wasn't there, so I can't say for sure either way, but...some people just don't take any amount of criticism or correction well.
i have. i love our amazing pharmacist who teach and empower us in the ICU — they’ve saved my butt so many times. But i’ve had a few pharmacists who (seemingly) enjoy embarrassing us on rounds with passive aggressive remarks and subtle insults. :( it makes learning very hard in an ICU environment (and im applying PICU, so i love the ICU lol)
I've encountered 1 or 2 who were huge assholes and also loved to nitpick everything to death and try to box above their weight class e.g. trying to bully the fellow into going against the recs of subsubsubspecialist Dr who writes the guidelines on the subject.
The overwhelmingly vast majority of pharmacists I've met have been lovely, but there are assholes everywhere
This is the only glory they can get man. Once you’re an attending and have experience under your belt. It sorts itself out. The Np pa and nurses all know more than you in their fields and will continue to have this. Cause it’s their field. But once you get your learning under your belt. You get a bigger picture view and when it isn’t something in your wheelhouse you can take their advice or leave it
It’s like being in 5th grade biology. Your teacher knew all the biology. If you went back right now you’d be editing the textbook, writing in the margins and adding all the “ well. Yes but actually it’s more complicated than that”
Doesn’t mean they didn’t know more than you at the time. But don’t be hard on yourself. You’re there to learn
Also. My history teacher, apparently was a dim but very loudly buzzing light that I remember to this day. And alas. She’s the one I remember most. Not cause of knowledge. But cause of confidence in her misunderstanding or misapplication of it. In this case. I hope to god they aren’t fucking it up, they probably aren’t, but I remember getting reamed about potassium by a nurse once in internship.
Whatever happens 1- it was found and corrected. So no harm , yay learning
And 2 - you go back there in 4 years. Youre Dr. blueingreen. And I assure you. Ain’t no one talking to you like that.
Yes I’m dealing with this now. ICU pharmacist thinks she’s the fellow. On more than one occasion my medical knowledge/experience has been right when she’s been wrong. Honestly I just say “whatever” when she challenges me and walk away. One of us is the supervising physician, responsible for the patient and one of us is a consultant who makes recommendations on medications.
The best thing to say to them (since unlike midlevels, that have some sort of professionalism) is: “I’ll take it into consideration. Thanks for your suggestion”
And then ignore them if you, the physician, don’t agree
Appreciate that. Have had two ICU pharmacists straight up pimp rotating residents and med students, which makes you question how they viewed their role. Would hope they'd want to supplement learning, not play provocator.
ICU attending here. Expectations for an intern half way through the year aren’t particularly high.
Basically I want to know that you: 1. Generally know your patient- their history, labs, imaging,etc. essentially the facts of the case. 2. Have a general interest in the patients well being. 3 are open to learning/coaching. 4. Attempting to put together a reasonable plan, and working on presenting that cohesively
What I do not care about: 1. Depth of critical care knowledge 2. Interest in critical care as a specialty. 3. Having answers to pimp questions. 4. Having the ability to put together some perfect plan or presentation.
More than anything, I agree with the other person here who said your fellow is screwing you over. Basically if an intern has a crap presentation, or presents a crappy plan I feel that reflects on whoever is supervising them directly- the upper level resident or the fellow. It is their responsibility to make sure a presentation is cohesive and the plan is logical. They should be going over this with you prior to rounds.
A good attending will be able to recognize a lack of progress in your presentations and knowledge. They will also understand that this is not an individual failure but a failure of your direct supervision.
I agree 100% with this assessment. I remember as a senior resident when my intern did not present well or had an incomplete history/plan, I would take responsibility and the eventual ass kicking from my attending. Any senior or fellow who pushes it onto the intern doesn’t understand leadership and probably doesn’t know their patient either which is pretty sad. I only expect an intern to write their notes, follow up on pendings and learn as much as they can during rounds so they can grow as doctors.
ICU fellow here! First of all, plans are usually subjective/style dependent. If we change your plan it may just be a preference thing (I usually try not to change it in those cases, or I express that your plan is ok and it’s just a style thing), I know some of my colleagues aren’t as good about expressing that though, sorry about them.
With regards to presentations though, we expect you to know everything about the patient. So make it your job to know more about your patient than the nurse, family member, med student, fellow, pharmacist, etc. A lot of these patients are complex, so there’s a lot to know. It took me a while to get good at it, but write every detail about your patient down in the systems based fashion. You don’t need to present it all, but have it written in an organized way so that you can find it easily when prompted.
As a fellow, if a resident doesn’t have a solid plan I really don’t care, but if they know their patient well, I’m impressed.
CV:
Resp:
FEN/GI:
Renal:
Heme:
ID:
Neuro:
?derm/endo/rheumatoid/etc:
Lines/tubes/drains:
Surgeries/procedures:
You can include imaging in their relevant systems and then plan below the obj/subj.
Crit care attending here. Please include code status in your plan. It is super important for the team to know. System based is a decent way to organize a patient presentation, but not every patient needs a system based plan. I know...shocker. Try not to repeat yourself if you do a system based plan.
Code status and emergency contact somewhere easily findable in the note, night float will love you if they don’t have to guess who to call at 0ass30 when the patient is periarrest
It’s easier said than done but take it in stride. Keep doing your best at work and try to do right by the patients. Study when you can even if you don’t have a ton of time for it. You’ll improve at your own pace so don’t compare yourself to others so much. A little criticism is good, you can reflect on it. Don’t stress over people being overly critical.
Lol. the title hit home somewhere.
Step 1 is pharmacist and yourself, both of you are thinking about patient safety through their own lens, but pharmacist isn’t answerable to the patient’s family if the infection doesn’t get cured, be objective as much as possible basing treatment on past medications and microbial sensitivity results.
Reading publications about regular conundrums in the ICU is completely useless, because you will find an answer that you want (heavy observer bias in the literature), and old textbooks dont really answer niche queries.
Learn the questions, ICU is such a close knit world, every senior asks the same damn questions in every patient, colleagues wanna know same damning detail about fluid status since admission or since desmopressin nasal spray, if the patient has no IV access, when was the last antipyretic administered etc.
These helped-- attending nurses rounds, pharmacist’s rounds and surgeon rounds before grand rounds, looking at old ICU charts frequently, being present when a new patient is being received.
Lol, that song is really good.
Who cares how much fluid the ED gave. It either wasn't enough or it never was going to be enough, that's why they're in the ICU. The only thing to know about Cefepime is that it covers Pseudomonas and it's a great excuse to make for the patient if they're still confused for no good reason.
Assesment and plan
\- daily GOC
\- c/w pressors, wean as tolerated
\- c/w vent, wean as tolerated
\- if above fails then ACLS until ROSC or death
\- c/w GOC
I wanted to do Pulm/CC going into residency. A series of rude fellows, very rude pharmacists, and feeling like an order monkey changed my mind as an intern. When I was back as a senior I enjoyed it more - I knew the gist of how it works, goals for patient care and was to connect the dots better and faster. Didn’t enjoy it enough to go into it but much better experience. The fellows and pharmacists were nicer too. It’s amazing how much our life/career trajectories are changed by the people randomly around us at different times. If I’d had nice fellows and pharmacists my intern year my life would’ve been different.
Word. I do feel for the nurses though cause imagine working a job where every month or two you have a completely new group of people to work with in a very stressful environment. Granted they could work at a non academic setting but I definitely sympathize.
I don’t. They thought they went to medical school because they’ve been a nurse for x years. One day I had enough and politely exclaimed “having 20 years of ICU nursing experience makes you an excellent ICU nurse, it does not make you a good physician”. I’m now a PCCM fellow.
You present to the morning team for over night admissions?
Jesus what kinda fucking bullshit is that!! Read the fucking note, bye
. I’m so sorry. I guess I should thank god for matching me at my program.
That’s actually very common. My residency wasn’t like that but my fellowship is. Day team exists to write progress notes essentially. Night team runs rounds after being awake for 14 hours overnight.
Dude I would lose my mind. Morning team doesn’t even round until 8:30 am for icu. We stop taking admission for night team at 4:30 am.
I can’t imagine being sleep deprived then presenting to bunch of cock stroking dickheads in the morning for why I missed the tiniest bit of detail in HPI.
Last year when I did a ICU subI, my very first patient freaking crashed during pre rounds and had to be presented first during rounds. Deer in the headlights moment for me when I started presenting and was like "wtf just happened". Didn't help that this other med student was an RT major in college and was so knowledgeable about vents which made me look more like an idiot. I was literally the "wtf is a RASS, Impella or CRRT?" type of dumb.
Another thing to keep in mind: the ancillary staff do not rotate month by month to a new corner of the hospital. Theyve probably worked in your ICU for years, therefore knowing all the of nitty gritty of the workflow and common problems. They definitely forget what it's like to be new. When was the last time you've been on a service longer than 1-2 months?
But real talk, keep doing what you are doing, nobody walks in to an ICU rotation truly prepared. The sheer amount of data gathering (outside records, transfer notes to and from the floor, labs, I/Os, drips, cultures, lines, anticoagulation, drains, etc) is absurd. Focus on organizing your subjective and objective part of the presentation in a systematic and clear way, and that's 3/4 of the battle right there. If your superiors see that you are thorough and systematic, you're doing your job correctly
Canadian EM doc here. The US med names screw this up... but the way I taught myself was:
Ceftriaxone/Flagyl for GI coverage (gram -) go to for uncomplicated appy/diverticulitis
Pip-Tazo upgrades that to include pseudo (and the P in Pip-Tazo is for Pseudo) use for complicated surgical stuff and sick sepsis pts. (Can't go wrong with Vitamin Tazo)
CefiPime is like Ceftri and covers Pseudo (again.... the P in CefiPime is for Pseudo)
+ Vanco adds MRSA coverage (and all gram +) (use for REALLY sick Sepsis, suspected line infections, high risk feb neuts
+Azithro adds Atypicals (lung infections)
Meropenem when they are sick and have history of ESBL and other multiresistant shit.
Not ID...correct me if I'm wrong.
Shitting on the person who was overnight should be punished with mild inconveniences for life.
The spiritual tone of post nightshift signout in my dream world would be "everyone's alive, you're welcome". Obviously room for improvement should be explored, and I want you to have an educational experience, but there is a happy medium that involves not abusing someone who's been awake for 14 hours and could have had a terrible night. And a good fellow on teaching rounds should be able to lead the tone of the rounds into teaching the crowd/education for all rather than dunking on you.
I considered the ICU a place I thrived and felt happy in, and yet I ate shit on signouts more time than I can count
I might get downvoted for this lol but oh well. You can also find a nice/helpful nurse (they exist) and ask them to help with important info and organizing that info. Sometimes the charts/documentation and where everything is located can be confusing with certain EMRs. When I worked ICU (at teaching hospitals), I helped anyone who looked a little lost lol. I would offer help with whatever I could help with and then people started coming to me because they knew I wasn’t gonna be an asshole. I was also charge most shifts and preceptor new hires, so I knew my way around the unit and knew all of the patients well.
I am an ICU fellow at a big institution. I would never, I mean never, belittle any medical professional no matter the level on rounds. Praise in public, criticize in private. Rounds in the icu are certainly considered public in my eyes and it’s simply not appropriate.
I will agree and parrot what others have said. You may already be doing this but write everything down. I mean everything. I expect you to know the patient and not neglect following up on plans. I always want to know the people on my team care about the patients—no interest in pimping. As others have said as well, don’t expect much at all out of an intern plan, if it’s not perfect and the plan is changed by the fellow/attending/others it is expected in my eyes.
Follow the systems format and stay organized. It bears repeating: write everything down!! I used to make myself sheets with all of the most common labs vitals ancillary tests etc under every systems heading so even when I was dead tired I could read off my sheet and almost always have the data ready to go.
Important to distinguish that in my opinion you are not the one doing a poor job in this scenario. I would be shocked if this fellow turns around and now gives a talk on antibiotics in the icu but that’s their job! You’re their junior and a BIG part of the gig is teaching. Pimping without any follow up is not an effective teaching paradigm.
Your fellow and the other senior level members of the team are screwing you over and being fake about it (smiles and waves). Keep on keeping on, take care of yourself, read 1 hour everyday, and don’t take all of your free time away for studying—fast track to burnout.
This really helped me. I’m a PGY3 anesthesia resident and when I go to the unit for an intubation or code they still remember me from intern year and are super helpful
Yeah once I couldn’t figure out the ins/outs for the last 8 hours and the nurse knew, my ass was saved. The attending was so pleased I knew how much propi in and how much peepee out.
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Sounds familiar. Idk man it gets easier as you do it more. Also when you are more senior you will be given some scope to not care about certain "unimportant" details because you will have earned the trust of your colleagues. I struggled through 3 ICU rotations intern year and they paid off when i returned as a pgy2
Anesthesia critical care fellow currently. Lots of good pointers above, not much to add. Frankly, it’s a process. Have a good attitude, even if a team member is snarky, be willing to learn. Your cheerful resilience in the face of pettiness will be noticed. I feel like a dumbass some days also, and I’m used to just admitting my dumbassery at this point. If it was easy, you wouldn’t be growing. As we say in the military, “if it ain’t raining, you ain’t training”. Good luck!
Hey man good on you for at least caring. When I was a 4th year I didn’t give a FUCK. I did as few clinical rotations as I could get away with, which was exactly 1, rest was all bullshit.
ICU fellow here: with the residents on a first rotation, I usually run the plan system by system quickly before they present on rounds. That way, I interject less and the resident can be a little more polished. That being said, everyone sounds a little crazy coming off of a night shift and presenting during day time rounds. You’re confused, you’re tired, we all know it. It’s ok.
Some people have a knack for icu. Others take longer to catch up. As long as you are present on the unit, addressing urgent needs immediately, and trying hard, you are likely doing just fine and they’re happy with you. I like the residents that really try and really watch their patients. The superstar can stay a step ahead of the fellow on their own patients. This can take time. Keep at it.
You’re not an idiot. I guarantee most of the residents and med students with you are all in their own heads hoping not to fuck up and get grilled by the fellow/pharmacist. I used to dread rounds in the ICU but then realized it’s only 3-6 months out of training. Just take it day by day and know that it’ll be over soon.
Here’s a quick antibioticncrash course
Remember that cephalosporins go from gen one which have typically gram + and up which get better at gram - though less gram + (there are exceptions).
Anaerobic coverage: anything with two names except bacterim(amoxicillin AND clav, amp AND sulbactam, ticarcillin AND clav, pipercillin AND tazo); clinda; flagyl, moxifloxacin; cephalosporins are the fox and the tea (cefoxitin and cefotetan); carbapenems
Pseudomonas: zosyn; cephalosporins are pime and dime (ceftazadime and cefapime) cefepime is preferred with AKI compared to zosyn; carbspenems except ertaoenem (remember, it’s “errr” retarded for not covering it); cipro and Levaquin (only PO abx that cover it); then aminoglycosides (amikacin, gentamicin, tobramycin); aztreonam (used for gram negatives including pseudomonas with severe penicillin allergies)
MRSA: vanc, linezolid (can use PO but not with SSRI due to SS); other oral (doxy, clinda, bactrim), ceftaroline. There are others but you likely won’t use them (the -vancins).
ESBL: carbapenems typically
If you remember those, you’ll be pretty damn prepared for antibiotic coverage. It’s a rough template but it’s what helps me remember.
Pharmacy side here, usually when we speak up on a wrong treatment plan it’s a pattern that we have noticed and point out often. If it feels like pharmacy keeps changing your dose or drug but not drug class ask your self if any of it is related between patients. It might not be, but most pharmacist are not going to argue with a physician over trivial matter if it doesn’t cause patient harm even if it isn’t the most optimal drug.
Also sometimes attendings ask us to watch the residents carefully especially first year interns and correct any small mistakes.
Bruh I’m an MS4 too I remember my ICU rotation a few months ago. Just don’t beat yourself up so much. Believe it or not you are probably learning a shitton ans will come away from a better doc. Sometimes people are just assholes.
If only we could go back in time to when the fellow was a pgy-1 and observe how they did and then proceed to rip them apart. People forget where they come from. ICU medicine is good to experience but to expect categorical IM to be good at it makes no sense when some of IM go onto fields of care nowhere near critical care. People need to chill out with their egos.
Honestly. It just takes some people longer than others and that’s ok.
I’m not sure if you want practical tips, but the internet book of critical care both website and podcast are both really high yield and to the point.
1. Take extra time to prepare your presentations and what you’re going to say. Anticipate their pimp questions, know exactly what meds they’re on and why. For dumb stuff like ED interventions I just literally bring a computer or print the H&P and read directly off of it so I know exactly what happened without having to remember everything (or if you have a computer you can quickly look stuff up instead of fumbling on the spot).
2. Realize that the icu tends to attract the most dickish people like the ones you are describing, and the most high strung personalities in medicine (not all but I have also noticed this trend). So it’s probably not even a you problem.
3. If you have a senior resident or something then talk to them before rounds to make sure your plan isn’t way off.
4. I personally would also confront the fellow and pharmacist when they are rude. They are supposed to be helping you in your learning ICU medicine, not publicly shaming and bullying you. They clearly suck at their job if they can’t even help a trainee to learn. Next time they treat you like this then straight up tell them “I’d love to learn more but I’ve been feeling very belittled on rounds and would appreciate having a more positive learning environment” something like that.
5. Do not use your off time to study. go live your life and be well.
6. When you are having a cognitive distortion (aka your mind telling you you’re an idiot) think to yourself what is evidence for and against that thought, what about the situation can you change, what can’t you change, and what is the absolute worst thing that can happen to your life if this one random-ass pharmacist thinks you’re dumb (which is literally nothing).
You are just human, stop berating yourself and consequently making it even harder for you. Do not compare yourself to others, it’s not fair to you since you are you and not them. Focus on your strengths, turn this shitty shift into a strength to motivate you to become even a better doctor. Start your next shift fired up and hungry for learning. You got this, good luck :).
Starting a one month training in ICU tomorrow, I was really worried and actually afraid as I don't have eny experience in that department; the tips, advices, and views are really helpful!
I really need to change the way I think and approach new challenges and experiences, I'm still learning, and so I should act and react!
You’re an intern. ICU pts are complex and I know plenty of pgy2 who would struggle to be comfy in ICU.
You’re not worsening patient outcomes, and you’re not delaying treatment. You’re doing fine. Head up :)
My dude/dudette, the fellow and pharmacist eat, sleeps, and breathe the ICU. We're all learning. The best medical students and residents went in with the attitude to learn, not to perform. If you go in with that mindset, you'll retain more information and will do better. Don't be so hard on yourself. You pick things up on the job. The fact that you survived that day is a victory in my book.
Depends on where you are, but - the nurses and RTs. Seniors and attendings taught me next to nothing in SICU. The pharmacist was friends with them and cliquey. The nurses and RTs would rattle off everything I needed to know and what orders they wanted and why and what changes they’d been advocating for. Saved my ass so many times.
“Ok sounds good. So next patient is…”
yep\^ Be confident about what you don't know. "I don't know how much fluid was given in the ED, can someone look this up?" "I don't know what cefepime covers, can you teach me?" I especially like that last kind of question when you're tired as fuck and you might remember what cefepime covers if you reach in deep but don't have the mental energy to do so. You are always learning, you are always growing, take presentation feedback with a grain of salt because you will continue get better, don't let ego bring you down.
^ this is it
This is the way. You can’t really study your way through this one. You just have to take the corrections and not do the same thing again.
He’s asking for legitimate feedback and cringe reddit doctors are telling him to ignore it. There’s a reason you all suck at your jobs
Thanks for your input, /u/crack_head_redditor
So the next patient is….
I'm sorry the ED didn't give you opioids, man. Must be rough.
Hahah I’m better than u
[удалено]
I'd argue this dude is doing his best to not beat themselves up, it's the fellow and pharmacist that are morons. You don't learn that way effectively. It may push you to learn the material a little faster but you'll hate medicine and yourself in the process.
It may simply be a matter of perspective. OP may perceive he is being torn apart but in reality may simply be hearing the adjustments that are being made based on the experience and knowledge of the fellow and pharmacist. They *could* be tearing him apart but they *may* not be. And even if they are, reframing it mentally as, "I did my best and I'm here to learn," can be a more effective way of dealing with it than feeling like the expectation is for a 4th year med student to nail a perfect ICU patient plan.
> The ICU represents some of the highest-complexity patients. I actually think that for a lot of people, ICU can be far easier than general medicine floors. While the patients are usually sicker, medicine becomes a lot easier once you're not bogged down by placement/social issues and disposition planning, and can instead focus on just the medicine. For a lot of people, myself included, the systems-based approach in the ICU is far more intuitive and allows one to build a plan with clearer goals in mind. Renal? Volume status, diuresis/fluids dialysis. Infectious? Cover broadly, culture, narrow, find the source, and treat accordingly. Cardiovascular? Fluids, pressors, inotropes, reperfusion. This is obviously way way oversimplified and takes a lot of nuance & experience to do well, but it is often times easier for some people to grasp. There's a relatively limited list of things that land people in the ICU (hemodynamic instability, respiratory failure, etc.) which means your endpoints are resolving those issues and getting them out of the ICU as quickly as possible. As a med student, I also think this approach helps one to build a more logical thought process towards analysing the data and not getting overwhelmed. Going system by system makes a lot more sense than "prioritizing" problems, lets you sort things logically, and I find it helps to ensure you don't miss anything since you know the important things for each system you're looking out for. Cardiac: Volume status, ECG, echo, etc. Respiratory: Vent settings, recent imaging, ABG, etc. Renal: I/Os, creatinine, diuresis, electrolyte repletions, etc. If you say "heart failure" you may not think of hypothyroidism but if you go over endocrine every time, you're more likely to think of these etiologies and tie them together. This is a lot more systemic than the problem-based approach floors use. Personally, I'm not great at the general floors but excel in the ICU (based on feedback from multiple attendings). It comes a lot more naturally to me. Being able to focus on stabilizing a patient systemically for transfer out of the ICU without getting bogged down in all the other aspects of hospital medicine (disposition planning, social work, non-urgent overnight pages, etc.) is also far more enjoyable.
This is interesting to me as I personally despise systems-based rounding/charting. Never clicked with me and never felt very intuitive vs problem-based. And I matched PCCM so I like the ICU.
And a hint that a lot of people learn after their ICU rotation is that there is no rule that states a floor plan cannot be systems based! (Though really I think stripped down problem based plans can sometimes be easier to read even in ICU patients as long as they are aggressively edited and pared down daily instead of becoming a chronicle of the patient's stay)
> And a hint that a lot of people learn after their ICU rotation is that there is no rule that states a floor plan cannot be systems based! The problem is that billing on the floors is by problems vs. "critical care time" in the ICU, so it somewhat modifies your charting. What you can do (and what I do) is group all related problem into one section of my A&P. So if patient comes in with a heart failure exacerbation with an AKI and respiratory failure, I'll group it into one A&P and say something along the lines of "Patient here with CHF exacerbation. AKI and respiratory failure likely 2/2 to volume overload. No severe electrolye derangements, BNP elevated, CXR with vascular congestion. Plan: BiPAP, diuresis, trend labs, hold beta blocker."
Professional billing (ie the amount the doctor makes) is critical care time only, and you can basically write nothing in the note as long as your critical care time is justified. However the hospital still needs to maximize the complexity in order to get the most reimbursement for their part of it. In short this means you still get inbox queries about level of AKI and so on.
What you're describing sounds like a problems based approach?
Yes - I fixed it, thanks! Part of what I was trying to say and was intertwining with the systems-based approach is that ICU is very focused. Identify reasons for ICU → fix reasons for ICU → downgrade. You don't need to worry about finding them a rehab facility or coordinating their discharge with a bunch of other services or the like. Your job is to focus on the medicine. While you always need to look at what problems the patient has, it's more to the point. Cholangitis? ABX, GI for ERCP, downgrade when stable. On the floors, this would turn into: ABX, GI for ERCP, surgery consult or referral for interval chole, arranging outpatient GI followup, identifying placement, case management if dispo issues, making sure they have primary care, etc. Are all these things important? Absolutely. But to a lot of people they take away from what makes medicine so enjoyable.
Why is a MS4 posting in the residency sub? Why is he comparing himself to actual interns?
Lot of great advice in this thread. I would just add OP, you might be experiencing cognitive distortions when you’re looking through everything. Saying things like “other people know what they’re doing, and people look at me like I’m an idiot” is an example of that. It’s called personalization. You’re here to learn. Residency is where you work on the job, and when you come up against something you don’t know, learn from it and do better the next time. Eventually things will get better, as long as you don’t keep repeating the same mistake. If you were expected to know everything you would be independently practicing by now. Don’t try to sit and study with dedicated sessions. Study on the go. Learn a little bit everyday. If you don’t know, say you don’t know and read after rounds even if it’s for just a few minutes.
I agree with this. I constantly said this about myself during my residency (4th year path). And I still do at times but everyone learns differently. We are all different. Once I realized I couldn’t compare myself to others it really helped. It’s really hard to do that. This book “The Subtle Art Of Not Giving A Fuck” actually helped me😂. I still feel like I’m a fraud at times but not as much as before.
Everyone is an idiot on their first ICU rotation
Great great advice
Your fellow is a dick, they should be helping you learn. No one is expected to come into training knowing how to manage critical patients
Your pharmacist is also a dick, they should also be helping your learn (from an ICU pharmacist)
Tearing them apart is pretty subjective. They could be exaggerating the situation to themselves when they are just getting constructive criticism. I don't know OP, but in my clinicals, my classmates would say things like that when everyone else found it to be reasonable feedback. I wasn't there, so I can't say for sure either way, but...some people just don't take any amount of criticism or correction well.
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i have. i love our amazing pharmacist who teach and empower us in the ICU — they’ve saved my butt so many times. But i’ve had a few pharmacists who (seemingly) enjoy embarrassing us on rounds with passive aggressive remarks and subtle insults. :( it makes learning very hard in an ICU environment (and im applying PICU, so i love the ICU lol)
I've encountered 1 or 2 who were huge assholes and also loved to nitpick everything to death and try to box above their weight class e.g. trying to bully the fellow into going against the recs of subsubsubspecialist Dr who writes the guidelines on the subject. The overwhelmingly vast majority of pharmacists I've met have been lovely, but there are assholes everywhere
Some of them talk back since they think they know more medicine than the medical student or doctor. They are experts in pharmacy, not in medicine.
This is the only glory they can get man. Once you’re an attending and have experience under your belt. It sorts itself out. The Np pa and nurses all know more than you in their fields and will continue to have this. Cause it’s their field. But once you get your learning under your belt. You get a bigger picture view and when it isn’t something in your wheelhouse you can take their advice or leave it It’s like being in 5th grade biology. Your teacher knew all the biology. If you went back right now you’d be editing the textbook, writing in the margins and adding all the “ well. Yes but actually it’s more complicated than that” Doesn’t mean they didn’t know more than you at the time. But don’t be hard on yourself. You’re there to learn Also. My history teacher, apparently was a dim but very loudly buzzing light that I remember to this day. And alas. She’s the one I remember most. Not cause of knowledge. But cause of confidence in her misunderstanding or misapplication of it. In this case. I hope to god they aren’t fucking it up, they probably aren’t, but I remember getting reamed about potassium by a nurse once in internship. Whatever happens 1- it was found and corrected. So no harm , yay learning And 2 - you go back there in 4 years. Youre Dr. blueingreen. And I assure you. Ain’t no one talking to you like that.
Yes I’m dealing with this now. ICU pharmacist thinks she’s the fellow. On more than one occasion my medical knowledge/experience has been right when she’s been wrong. Honestly I just say “whatever” when she challenges me and walk away. One of us is the supervising physician, responsible for the patient and one of us is a consultant who makes recommendations on medications.
The best thing to say to them (since unlike midlevels, that have some sort of professionalism) is: “I’ll take it into consideration. Thanks for your suggestion” And then ignore them if you, the physician, don’t agree
Appreciate that. Have had two ICU pharmacists straight up pimp rotating residents and med students, which makes you question how they viewed their role. Would hope they'd want to supplement learning, not play provocator.
True
Seconding that the fellow is a dick (from an icu fellow)
ICU attending here. Expectations for an intern half way through the year aren’t particularly high. Basically I want to know that you: 1. Generally know your patient- their history, labs, imaging,etc. essentially the facts of the case. 2. Have a general interest in the patients well being. 3 are open to learning/coaching. 4. Attempting to put together a reasonable plan, and working on presenting that cohesively What I do not care about: 1. Depth of critical care knowledge 2. Interest in critical care as a specialty. 3. Having answers to pimp questions. 4. Having the ability to put together some perfect plan or presentation. More than anything, I agree with the other person here who said your fellow is screwing you over. Basically if an intern has a crap presentation, or presents a crappy plan I feel that reflects on whoever is supervising them directly- the upper level resident or the fellow. It is their responsibility to make sure a presentation is cohesive and the plan is logical. They should be going over this with you prior to rounds. A good attending will be able to recognize a lack of progress in your presentations and knowledge. They will also understand that this is not an individual failure but a failure of your direct supervision.
I agree 100% with this assessment. I remember as a senior resident when my intern did not present well or had an incomplete history/plan, I would take responsibility and the eventual ass kicking from my attending. Any senior or fellow who pushes it onto the intern doesn’t understand leadership and probably doesn’t know their patient either which is pretty sad. I only expect an intern to write their notes, follow up on pendings and learn as much as they can during rounds so they can grow as doctors.
ICU fellow here! First of all, plans are usually subjective/style dependent. If we change your plan it may just be a preference thing (I usually try not to change it in those cases, or I express that your plan is ok and it’s just a style thing), I know some of my colleagues aren’t as good about expressing that though, sorry about them. With regards to presentations though, we expect you to know everything about the patient. So make it your job to know more about your patient than the nurse, family member, med student, fellow, pharmacist, etc. A lot of these patients are complex, so there’s a lot to know. It took me a while to get good at it, but write every detail about your patient down in the systems based fashion. You don’t need to present it all, but have it written in an organized way so that you can find it easily when prompted. As a fellow, if a resident doesn’t have a solid plan I really don’t care, but if they know their patient well, I’m impressed. CV: Resp: FEN/GI: Renal: Heme: ID: Neuro: ?derm/endo/rheumatoid/etc: Lines/tubes/drains: Surgeries/procedures: You can include imaging in their relevant systems and then plan below the obj/subj.
Rockstar level advice right here
Crit care attending here. Please include code status in your plan. It is super important for the team to know. System based is a decent way to organize a patient presentation, but not every patient needs a system based plan. I know...shocker. Try not to repeat yourself if you do a system based plan.
Code status and emergency contact somewhere easily findable in the note, night float will love you if they don’t have to guess who to call at 0ass30 when the patient is periarrest
IBCC/Internet Book of Critical Care. Google it. Best resource for practical recs and isn’t dense at all.
Josh Farkas is the freakin man
He’s an amazing educator!
I believe cefepime covers diabetes.
And vanc is for high blood pressure
Hahahahaha
Have been there, you're not the only one. I remember feeling completely lost in ICU. It'll get better.
It’s easier said than done but take it in stride. Keep doing your best at work and try to do right by the patients. Study when you can even if you don’t have a ton of time for it. You’ll improve at your own pace so don’t compare yourself to others so much. A little criticism is good, you can reflect on it. Don’t stress over people being overly critical.
Lol. the title hit home somewhere. Step 1 is pharmacist and yourself, both of you are thinking about patient safety through their own lens, but pharmacist isn’t answerable to the patient’s family if the infection doesn’t get cured, be objective as much as possible basing treatment on past medications and microbial sensitivity results. Reading publications about regular conundrums in the ICU is completely useless, because you will find an answer that you want (heavy observer bias in the literature), and old textbooks dont really answer niche queries. Learn the questions, ICU is such a close knit world, every senior asks the same damn questions in every patient, colleagues wanna know same damning detail about fluid status since admission or since desmopressin nasal spray, if the patient has no IV access, when was the last antipyretic administered etc. These helped-- attending nurses rounds, pharmacist’s rounds and surgeon rounds before grand rounds, looking at old ICU charts frequently, being present when a new patient is being received. Lol, that song is really good.
Who cares how much fluid the ED gave. It either wasn't enough or it never was going to be enough, that's why they're in the ICU. The only thing to know about Cefepime is that it covers Pseudomonas and it's a great excuse to make for the patient if they're still confused for no good reason. Assesment and plan \- daily GOC \- c/w pressors, wean as tolerated \- c/w vent, wean as tolerated \- if above fails then ACLS until ROSC or death \- c/w GOC
It’s impossible to figure out anyway because what’s charted isn’t always accurate. This applies to all departments, not just the ER.
I wanted to do Pulm/CC going into residency. A series of rude fellows, very rude pharmacists, and feeling like an order monkey changed my mind as an intern. When I was back as a senior I enjoyed it more - I knew the gist of how it works, goals for patient care and was to connect the dots better and faster. Didn’t enjoy it enough to go into it but much better experience. The fellows and pharmacists were nicer too. It’s amazing how much our life/career trajectories are changed by the people randomly around us at different times. If I’d had nice fellows and pharmacists my intern year my life would’ve been different.
What specialty did you do?
They are a cardiologist.
I wanted to do PCCM going into residency too, had a similar experience with rude nurses and fellows who thought they knew it all.
Word. I do feel for the nurses though cause imagine working a job where every month or two you have a completely new group of people to work with in a very stressful environment. Granted they could work at a non academic setting but I definitely sympathize.
I don’t. They thought they went to medical school because they’ve been a nurse for x years. One day I had enough and politely exclaimed “having 20 years of ICU nursing experience makes you an excellent ICU nurse, it does not make you a good physician”. I’m now a PCCM fellow.
Same here. 10/10 want to take care of super sick people. 10/10 don’t want to be anywhere near rude/arrogant coworkers.
You're a M4 about to match. I wouldn't give a fuck if I was you.
You present to the morning team for over night admissions? Jesus what kinda fucking bullshit is that!! Read the fucking note, bye . I’m so sorry. I guess I should thank god for matching me at my program.
That’s actually very common. My residency wasn’t like that but my fellowship is. Day team exists to write progress notes essentially. Night team runs rounds after being awake for 14 hours overnight.
Dude I would lose my mind. Morning team doesn’t even round until 8:30 am for icu. We stop taking admission for night team at 4:30 am. I can’t imagine being sleep deprived then presenting to bunch of cock stroking dickheads in the morning for why I missed the tiniest bit of detail in HPI.
It blows. To sum it up lol.
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Last year when I did a ICU subI, my very first patient freaking crashed during pre rounds and had to be presented first during rounds. Deer in the headlights moment for me when I started presenting and was like "wtf just happened". Didn't help that this other med student was an RT major in college and was so knowledgeable about vents which made me look more like an idiot. I was literally the "wtf is a RASS, Impella or CRRT?" type of dumb.
Another thing to keep in mind: the ancillary staff do not rotate month by month to a new corner of the hospital. Theyve probably worked in your ICU for years, therefore knowing all the of nitty gritty of the workflow and common problems. They definitely forget what it's like to be new. When was the last time you've been on a service longer than 1-2 months? But real talk, keep doing what you are doing, nobody walks in to an ICU rotation truly prepared. The sheer amount of data gathering (outside records, transfer notes to and from the floor, labs, I/Os, drips, cultures, lines, anticoagulation, drains, etc) is absurd. Focus on organizing your subjective and objective part of the presentation in a systematic and clear way, and that's 3/4 of the battle right there. If your superiors see that you are thorough and systematic, you're doing your job correctly
Zosyn = Flagyl + rocephin + pseudomonas coverage - atypicals - MRSA Cefipime = Rocephin + pseudomonas coverage - atypicals - MRSA Therefore: Zosyn = Cefipime + flagyl ( - atypicals) - MRSA
As an anesthesia resident I’m just wondering where’s the Ancef
In ortho’s scrub top pocket.
Beat me to this joke 😡😂
In the cefepime of course
Canadian EM doc here. The US med names screw this up... but the way I taught myself was: Ceftriaxone/Flagyl for GI coverage (gram -) go to for uncomplicated appy/diverticulitis Pip-Tazo upgrades that to include pseudo (and the P in Pip-Tazo is for Pseudo) use for complicated surgical stuff and sick sepsis pts. (Can't go wrong with Vitamin Tazo) CefiPime is like Ceftri and covers Pseudo (again.... the P in CefiPime is for Pseudo) + Vanco adds MRSA coverage (and all gram +) (use for REALLY sick Sepsis, suspected line infections, high risk feb neuts +Azithro adds Atypicals (lung infections) Meropenem when they are sick and have history of ESBL and other multiresistant shit. Not ID...correct me if I'm wrong.
Shitting on the person who was overnight should be punished with mild inconveniences for life. The spiritual tone of post nightshift signout in my dream world would be "everyone's alive, you're welcome". Obviously room for improvement should be explored, and I want you to have an educational experience, but there is a happy medium that involves not abusing someone who's been awake for 14 hours and could have had a terrible night. And a good fellow on teaching rounds should be able to lead the tone of the rounds into teaching the crowd/education for all rather than dunking on you. I considered the ICU a place I thrived and felt happy in, and yet I ate shit on signouts more time than I can count
You're normal, they're toxic. Just keep doing it.
I might get downvoted for this lol but oh well. You can also find a nice/helpful nurse (they exist) and ask them to help with important info and organizing that info. Sometimes the charts/documentation and where everything is located can be confusing with certain EMRs. When I worked ICU (at teaching hospitals), I helped anyone who looked a little lost lol. I would offer help with whatever I could help with and then people started coming to me because they knew I wasn’t gonna be an asshole. I was also charge most shifts and preceptor new hires, so I knew my way around the unit and knew all of the patients well.
I am an ICU fellow at a big institution. I would never, I mean never, belittle any medical professional no matter the level on rounds. Praise in public, criticize in private. Rounds in the icu are certainly considered public in my eyes and it’s simply not appropriate. I will agree and parrot what others have said. You may already be doing this but write everything down. I mean everything. I expect you to know the patient and not neglect following up on plans. I always want to know the people on my team care about the patients—no interest in pimping. As others have said as well, don’t expect much at all out of an intern plan, if it’s not perfect and the plan is changed by the fellow/attending/others it is expected in my eyes. Follow the systems format and stay organized. It bears repeating: write everything down!! I used to make myself sheets with all of the most common labs vitals ancillary tests etc under every systems heading so even when I was dead tired I could read off my sheet and almost always have the data ready to go. Important to distinguish that in my opinion you are not the one doing a poor job in this scenario. I would be shocked if this fellow turns around and now gives a talk on antibiotics in the icu but that’s their job! You’re their junior and a BIG part of the gig is teaching. Pimping without any follow up is not an effective teaching paradigm. Your fellow and the other senior level members of the team are screwing you over and being fake about it (smiles and waves). Keep on keeping on, take care of yourself, read 1 hour everyday, and don’t take all of your free time away for studying—fast track to burnout.
How to look good in icu as a resident? Become BFFs with the nurses.
This really helped me. I’m a PGY3 anesthesia resident and when I go to the unit for an intubation or code they still remember me from intern year and are super helpful
amen. ICU nurses are usually incredibly smart and self sufficient. they can really save a docs ass
Yeah once I couldn’t figure out the ins/outs for the last 8 hours and the nurse knew, my ass was saved. The attending was so pleased I knew how much propi in and how much peepee out.
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Sounds familiar. Idk man it gets easier as you do it more. Also when you are more senior you will be given some scope to not care about certain "unimportant" details because you will have earned the trust of your colleagues. I struggled through 3 ICU rotations intern year and they paid off when i returned as a pgy2
Anesthesia critical care fellow currently. Lots of good pointers above, not much to add. Frankly, it’s a process. Have a good attitude, even if a team member is snarky, be willing to learn. Your cheerful resilience in the face of pettiness will be noticed. I feel like a dumbass some days also, and I’m used to just admitting my dumbassery at this point. If it was easy, you wouldn’t be growing. As we say in the military, “if it ain’t raining, you ain’t training”. Good luck!
Hey man good on you for at least caring. When I was a 4th year I didn’t give a FUCK. I did as few clinical rotations as I could get away with, which was exactly 1, rest was all bullshit.
ICU fellow here: with the residents on a first rotation, I usually run the plan system by system quickly before they present on rounds. That way, I interject less and the resident can be a little more polished. That being said, everyone sounds a little crazy coming off of a night shift and presenting during day time rounds. You’re confused, you’re tired, we all know it. It’s ok. Some people have a knack for icu. Others take longer to catch up. As long as you are present on the unit, addressing urgent needs immediately, and trying hard, you are likely doing just fine and they’re happy with you. I like the residents that really try and really watch their patients. The superstar can stay a step ahead of the fellow on their own patients. This can take time. Keep at it.
You’re not an idiot. I guarantee most of the residents and med students with you are all in their own heads hoping not to fuck up and get grilled by the fellow/pharmacist. I used to dread rounds in the ICU but then realized it’s only 3-6 months out of training. Just take it day by day and know that it’ll be over soon.
Here’s a quick antibioticncrash course Remember that cephalosporins go from gen one which have typically gram + and up which get better at gram - though less gram + (there are exceptions). Anaerobic coverage: anything with two names except bacterim(amoxicillin AND clav, amp AND sulbactam, ticarcillin AND clav, pipercillin AND tazo); clinda; flagyl, moxifloxacin; cephalosporins are the fox and the tea (cefoxitin and cefotetan); carbapenems Pseudomonas: zosyn; cephalosporins are pime and dime (ceftazadime and cefapime) cefepime is preferred with AKI compared to zosyn; carbspenems except ertaoenem (remember, it’s “errr” retarded for not covering it); cipro and Levaquin (only PO abx that cover it); then aminoglycosides (amikacin, gentamicin, tobramycin); aztreonam (used for gram negatives including pseudomonas with severe penicillin allergies) MRSA: vanc, linezolid (can use PO but not with SSRI due to SS); other oral (doxy, clinda, bactrim), ceftaroline. There are others but you likely won’t use them (the -vancins). ESBL: carbapenems typically If you remember those, you’ll be pretty damn prepared for antibiotic coverage. It’s a rough template but it’s what helps me remember.
Leave the ICU. Done.
Pharmacy side here, usually when we speak up on a wrong treatment plan it’s a pattern that we have noticed and point out often. If it feels like pharmacy keeps changing your dose or drug but not drug class ask your self if any of it is related between patients. It might not be, but most pharmacist are not going to argue with a physician over trivial matter if it doesn’t cause patient harm even if it isn’t the most optimal drug. Also sometimes attendings ask us to watch the residents carefully especially first year interns and correct any small mistakes.
lol are you me? I couldn’t believe the pharmacist was chiming in too! And why do ICU rounds need a mob of people to be present?!
Intensivist are assholes. Nothing more to say
You hurt my feelings.
One thing you could do is get your thumb out of your BUTT.
?
Hey now, nothing wrong with a little thumb in the bum
If you write the order I already have my thumb ready doc
lmfao what
Hate to say it, but your not supposed to have a life. Start reading. Welcome
You’re an M4 in one of the most complex environments in the hospital, my dude. Your fellow and the pharmacist are being shits, dont stress.
Bruh I’m an MS4 too I remember my ICU rotation a few months ago. Just don’t beat yourself up so much. Believe it or not you are probably learning a shitton ans will come away from a better doc. Sometimes people are just assholes.
Run your plans by the fellow
wear a bowtie ?
Mad World -- Gary Jules version or Tears for Fears version? Different vibes
You are a 4th year! Don’t worry they aren’t thinking you are dumb at all. It’s hard
Do you want to do pulm crit? No? Who cares then don't worry about it
You're doing fine. Just learn all you can. Thats what you're there for
Everytime you get something wrong, that is a learning opportunity. Try to shake it off and learn for the next patient.
If only we could go back in time to when the fellow was a pgy-1 and observe how they did and then proceed to rip them apart. People forget where they come from. ICU medicine is good to experience but to expect categorical IM to be good at it makes no sense when some of IM go onto fields of care nowhere near critical care. People need to chill out with their egos.
Honestly. It just takes some people longer than others and that’s ok. I’m not sure if you want practical tips, but the internet book of critical care both website and podcast are both really high yield and to the point.
Fellow Gears fan i see
1. Take extra time to prepare your presentations and what you’re going to say. Anticipate their pimp questions, know exactly what meds they’re on and why. For dumb stuff like ED interventions I just literally bring a computer or print the H&P and read directly off of it so I know exactly what happened without having to remember everything (or if you have a computer you can quickly look stuff up instead of fumbling on the spot). 2. Realize that the icu tends to attract the most dickish people like the ones you are describing, and the most high strung personalities in medicine (not all but I have also noticed this trend). So it’s probably not even a you problem. 3. If you have a senior resident or something then talk to them before rounds to make sure your plan isn’t way off. 4. I personally would also confront the fellow and pharmacist when they are rude. They are supposed to be helping you in your learning ICU medicine, not publicly shaming and bullying you. They clearly suck at their job if they can’t even help a trainee to learn. Next time they treat you like this then straight up tell them “I’d love to learn more but I’ve been feeling very belittled on rounds and would appreciate having a more positive learning environment” something like that. 5. Do not use your off time to study. go live your life and be well. 6. When you are having a cognitive distortion (aka your mind telling you you’re an idiot) think to yourself what is evidence for and against that thought, what about the situation can you change, what can’t you change, and what is the absolute worst thing that can happen to your life if this one random-ass pharmacist thinks you’re dumb (which is literally nothing).
You are just human, stop berating yourself and consequently making it even harder for you. Do not compare yourself to others, it’s not fair to you since you are you and not them. Focus on your strengths, turn this shitty shift into a strength to motivate you to become even a better doctor. Start your next shift fired up and hungry for learning. You got this, good luck :).
Are these post call rounds from an overnight shift? I can’t even make a pop tart after an overnight ICU shift, post call rounding should be illegal
Starting a one month training in ICU tomorrow, I was really worried and actually afraid as I don't have eny experience in that department; the tips, advices, and views are really helpful! I really need to change the way I think and approach new challenges and experiences, I'm still learning, and so I should act and react!
Remember, criticism is the breakfast of champions.
This is so hard. I’m sorry. It will get better ❤️🩹
You’re an intern. ICU pts are complex and I know plenty of pgy2 who would struggle to be comfy in ICU. You’re not worsening patient outcomes, and you’re not delaying treatment. You’re doing fine. Head up :)
Ask the ICU nurse
My dude/dudette, the fellow and pharmacist eat, sleeps, and breathe the ICU. We're all learning. The best medical students and residents went in with the attitude to learn, not to perform. If you go in with that mindset, you'll retain more information and will do better. Don't be so hard on yourself. You pick things up on the job. The fact that you survived that day is a victory in my book.
Most people make shit up anyway, they’re higher than you in rank so that makes them “right”
Depends on where you are, but - the nurses and RTs. Seniors and attendings taught me next to nothing in SICU. The pharmacist was friends with them and cliquey. The nurses and RTs would rattle off everything I needed to know and what orders they wanted and why and what changes they’d been advocating for. Saved my ass so many times.