Feel like you don’t know what you’re doing? Good.

“I feel like I suck, and I don’t know what I’m doing.”

The text came from a previous student of mine who’s now working in the emergency department. I texted back:

“Good. That means you are starting to realize what the job really is.”

He was a great student. Began his career in the ED as a tech, then a nurse, a charge nurse, and finally, now an NP. At every step of his career, he had worked hard and excelled, but now felt the same doubts and fears we all felt when starting out.

A Fraud in Training

I still remember driving into my shift at our freestanding ED as a new grad, feeling terrified. I knew that at any moment, a puzzling case would come through the doors that exposed me for what I was — a total fraud. I constantly worried that the amazing mentors pouring their time and energy into me would become frustrated with my lack of knowledge and experience.

Looking back, I can still feel those moments.

I know what my colleague is going through. And I know what he has yet to realize: that he has climbed to the top of the hill, and for the first time, he can see the mountain ahead.

He has learned and seen just enough to realize the depth and breadth of medicine, and is starting to understand what he knows, and more importantly, what he doesn’t.

The Transition from ‘What’ to ‘Why’

Time and experience are the greatest teachers. When you first start working as an NP, you are focusing on the what and the how.

What tests need to be ordered on a patient with right upper quadrant abdominal pain.

How to perform a laceration repair and digital block.

But with time and experience, you will move on to the why and the when.

Why does the patient with a previous PE still have symptoms almost a year later?

When do you need to use Vicryl instead of plain gut?

When is it reasonable to discharge a patient with chest pain?

This process takes time. Experience and exposure will slowly build confidence, but along the way, there are several things you should do to set yourself up for success.

Get a Mentor

If there is one thing that I can attribute my growth as a clinician to, it's two amazing mentors that I had as a new graduate.

Both were attending physicians I'd known when I was a bedside RN. They were kind and patient, but also held me to a high standard. Feedback was given in real time, and advice was always actionable. They actively sought out cases to challenge me.

There were countless pearls and procedures to broaden my knowledge and experience. And most importantly, I could confide in them any issues or concerns that I had with total trust. I still work alongside one of those mentors, and he continues to help shape and mold new graduate APP’s into competent and efficient providers.

My other mentor moved to take advantage of an amazing opportunity, and to this day I hear his voice in my head like Obi-wan-Kenobi whenever I am faced with a dilemma.

Use Your Resources

Most hospitals and clinics put aside funds to help providers develop professionally, but often these resources go unused. Talk to your clinic lead or manager to see what resources are at your disposal. Subscribe to a podcast, get a bootcamp course, register for a conference. Take every opportunity to invest in yourself and your career. Whatever your yearly allowance for CME, use every cent of it every year.

Own Your Mistakes

About two years into practice, I lost a patient.

They were a bounceback, who had previously been seen by one of my mentors. The patient had the right labs drawn, the right scans ordered. The exam was reassuring, and the patient was discharged. I read the meticulous note from my mentor of the previous visit, repeated the essential tests, felt reassured with what I found, and discharged the patient home.

After several more visits to various clinics, the patient ultimately presented to the ED in extremis and passed soon after arrival. Subsequent autopsy revealed the subtle truth that had gone undetected during an earlier scan.

I knew that I hadn’t done anything wrong, but the guilt persisted. The patient was far younger than me, and left behind was a family with several small children. I started to second-guess myself, and whatever gestalt I had developed was fading. Self-doubt lingered until I worked a shift with that same mentor who had initially seen the patient. He confessed his own guilt and struggle over the loss, and his authenticity and humility helped me gain perspective and move forward.

Celebrate the Small Victories

One day, a young woman presented to the ED with persistent ear pain, despite multiple courses of antibiotics. She complained of worsening pain, and on exam she had a clearly red and angry ear canal. Pills and drops weren’t helping, the patient swearing that she had taken the medications as directed.

As I examined her, I noticed a small vesicular lesion on her lip. Looking closer I tracked several more lesions in her scalp, hidden by her long hair. After showing my findings to my attending, he quickly confirmed the diagnosis to the patient (a rare complication of HSV1), before turning to me with the highest praise an attending can give: “nice catch.” The whole encounter took maybe 10 minutes, in a fast-track chair. But it was a small win, and one that I was proud of.

Just Keep Swimming

There is an old saying in medicine: “That's why it's called practicing.”

Our job is dynamic and ever-changing. The learning curve is steep, the role demanding, and the stakes are high. Pilots don’t get to be “pretty good.” Engineers can’t build a “decent” bridge. Working as a provider carries the same burden of excellence, so set yourself up for success in every way that you can.

It was a long road to get where you are, but the journey never ends. It is an endless path towards better. Find good people to walk the path alongside you, and remember to help those along the way who look lost. Dory said it best, “Just keep swimming”.