Thursday, October 4, 2007

Adult Learners

You know how it goes, you’re an adult, you’ve been competent at what you do for umpty-ump years, then you go into a new field/specialty/approach and feel so frustrated at yourself because you’re not competent right off the bat. And if you’re really lucky, you also spend too much time comparing yourself with others.

So I’m three weeks into my palliative care fellowship. Since I’m only working two days a week, that’s six days, or an ooch over one work week. Coming in, G., the nurse practitioner I work with (under?) said “we’ll take it slow, I won’t expect you to start doing consultations until December.” That said, the first day, after seeing a patient she turns to me and says “so, what do you think? What should we do for his symptom?” And I stood there, mind blank, furiously trying to come up with something to say…and feeling like a complete failure.

This happened a few more times, and I either didn't have anything intelligent to say or couple of times I got stuck on something that wasn’t at all what she was looking at—again making me feel like a fool. It was also frustrating that we only had about three new consults over this time period, so I’m not getting a ton of exposure.

And then there’s the personalities and more comparing. This fellowship is interdisciplinary: there are two MDs, a social worker, a psychiatric post-doc, two chaplains and me (who is NOT an NP, and the position is theoretically for NPs). The docs, social worker and I share a room, the chaplains and psychiatrist are someplace else, as are their mentors. Were in the building G (not so fondly) calls the “little tin shack.” It’s a small building below the hospital (walk across an open area and then either take 4 flights of stairs or go into the parking garage and use the elevator). We have no windows (we’re on the downhill side of the building, so I think we’re actually underground). G, W., the social worker and T. the MD’s offices are across the hall from us fellows shared space. When I started, the only person there was one of the medical fellows. She’s rotating out to another setting next week. The social worker hasn’t started yet. So of course, I took the nicest open space. And then I get told I have to move b/c the social work fellow needs to have more access to the phone (there’s two in the room). And the current MD fellow tells the other one (they're overlapping by one week) “You take my space after I’m gone, it’s got all this nice work space, it’s like a command center.” So I feel like “once again the nurse gets the dregs.” Of course it’s not true, it’s reasonable, the MD is full time, I’m sure the social worker is on the phone a lot, but it still leaves me feeling like….less.

Can we talk overachieving, or at least trying to overcompensate? The new MD fellow has questions about the computer system. Hey, I’ve worked in the VA for four years! I can be of help here! And I try too hard, and D., the other MD fellow has to come to J’s aid. More feeling of “odd person out,” and “who do I feel I’m fooling?” Ah impostor syndrome thy name is marachne.

Going into Wednesday this week, I was feeling…mixed. On the one hand, I was thinking that maybe I could start “driving” a consult sooner than originally planned. I had, at G.’s urging, started to chime in when we were talking to patients. I’d asked a few good questions. On the other hand, I didn’t sleep hardly at all Tuesday night, so I was feeling pretty thick headed, and quite panicked when G suggests that I do the next new consult. Early in the day we went to visit a patient who had been given Very Bad News that came out of nowhere: it's an old story: the patient had symptoms for a while, thoght it was something else (old back injury, indigestion), comes in and finds out hes got widely metastasized cancer -- they don't even know what the primary is. Besides the shock, he was also pretty hostile because he’d had bad experiences with the VA in the past. The first thing we did was get his pain under control. Then it was time to wean him of the PCA and back onto oral meds so that he could go home, but he was skeptical that it would be as efficacious. G. was ready to roll with his desire and give him a Fentanyl patch if he didn’t want to go the oral route, but when we came up to visit on Tuesday he said that no, he trusted her (maybe not the rest of the docs or the system, but she had proved herself as accessible and an ally), and was willing to give it a try. On Wednesday we went back to check in with him before going home. I did what was perhaps the most speaking up to date: gave my “pain is easier to keep on top of rather than playing catch-up” speech, suggested he might want to take some breakthrough pain mediation before starting home (about a three hour drive away). As we were leaving the room, he says to me “excuse me, what was your name?” I tell him and he says “I just wanted to say thank you to you too.” That comment so made my day (I'm useful! I'm helpful! I have half a clue!)

At the end of the day, I go over to talk with G. about my progress. She says, “you’re doing great, you’re a lot further along than I thought you’d be at this point, you chime in appropriately and have good insight. And you’re a good fit with the rest of the team, which is one of the most important things." Finishes up by reaffirming that next week's plan is for me to take the lead on the consults.*

Nothing like outside affirmation to make one feel like a competent human being.

*We wound up not getting any new patients that day.


NocturnalRN said...

See, don't doubt yourself! You will feel more secure in time. Good luck!

MY OWN WOMAN said...

It's almost like magic, one day you don't know a darn thing and the next day it's a piece of cake. Good luck in your new position.