T-minus 10 months until I am a full-fledged attending physician. At this point in my training, like many of my peers, I am ridden with doubt. Did I study enough? Have I seen enough? Will I know the best evidence-based recommendations? Can I do this without the safety net that I am accustomed to?
Emergency medicine is a vast and ever-changing field. So let’s face it – three to four years is simply not enough time to master everything that you need to know. It is, however, enough time to build a strong foundation of knowledge that you can continue to build on throughout your career. If you can understand setting a foundation as the goal and have a plan of attack, what was previously overwhelming becomes very achievable.
One of the keys to success is recognizing the difference between clinical learning and classroom learning. Many attendings and senior residents will advise interns to study by going home after a shift and reading about something that they saw that day. I don’t disagree that this is a useful and necessary exercise. But in my opinion, it is inefficient if it is all that you do. It is inefficient because you are not working on a foundational framework to support these random pieces of knowledge. You should be actively learning and studying foundational topics and supplementing them with your clinical experience and follow-up.
So how can you approach doing this?
1. Set up and stick to a schedule for baseline studying.
Hopefully, you have Academic Chiefs and Faculty who will help you build a plan. If they cannot, then at the very least, they should be able to provide a schedule of block topics (i.e Trauma, Pulmonary, Cardiology, Pediatrics, etc). Use this to build your own plan. At this point in your educational career, you should know yourself and how you learn. Pick a primary resource to focus on. If you are a reader – pick one textbook and make a schedule that follows your block topics. If you like podcasts – breakdown EM:RAP Core Content. Divide up your board review questions and make sure you complete the whole question bank each year.
As you advance through residency, the resources that you use will change. Keep a list of the major RCTs that guide our practice and make sure you read and understand them. Pick a podcast or two and listen to each episode as it is published.
2. Supplement your baseline studying with clinical experience and questions.
One tip for success here is recognizing your current level of understanding. Listening to an advanced podcast on adjunctive therapy to vasopressors is great, but it is not going to help you learn or remember the physiology that guides vasopressor selection in the first place. You need to tailor your studying to your current understanding. As you progress through residency, you will shift from working on your primary knowledge to more advanced topics.
For example, imagine you just finished a shift where you had a very sick septic patient on multiple vasopressors. Your reactive studying may look like this:
Intern – 80% Foundational, 20% Advanced
Read chapters on resuscitation and shock
Review alpha/beta physiology
Podcast on basic vasopressors
PGY 2 – 40% Foundational, 60% Advanced
Podcast on evidence-based approach to vasopressors
Marik PE et al. Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A retrospective Before-After Study. Chest 2016.
PGY 3 – 20% Foundational, 80% Advanced
Primary Literature Search - “Management of Refractory Vasodilatory Shock”
Podcast on renal physiology in sepsis
Review Renin-Angiotensin physiology
3. Reevaluate for knowledge gaps and deficiencies.
Do not be afraid to go backwards. You are going to have faculty lectures and read journal articles that you don’t understand. Reflect on what it is that you are missing and review the basics. Circle back to the advanced topic after you have filled in the gaps.
Perhaps the best advice I can give and the advice that I gave to our own interns this year – is to start now and make studying a habit. Commit yourself to incorporating asynchronous learning as part of your work responsibilities. The further you let yourself get into your training without doing this, the harder it will be to make up for the lost time. This practice will set you up for continuous learning once you have completed your residency and you will undoubtedly be a better doctor for it.
Finally, I will tell you to remember that your residency is here to serve you. If you are not getting the education that you need, then be active and demand more. Ask your chiefs or your residency leadership for help. When you are solicited for recommendations on how to make your education better – speak up. You only have 3 or 4 years. Make the most of them.
Alexandra Davic, MD is a current PGY-3 Academic Chief Resident at Stony Brook Emergency Medicine.
Edited by Bassam Zahid, MD