The following manuscript was published as part of the March 2019 s/p The Match — One Year Later theme issue.
Dear Intern,
I see you. Yes — you over there. That unsuspecting look on your face tells me exactly what you must be thinking. You are no longer a medical student which means you are no longer invisible, or, at best, ancillary.
I see you. Still do not believe me? Just wait for that pager to start blowing up. You will get so many pages to place diet orders that you will want to go back to being invisible.
I see you walking into the building that will soon become your second home. Wearing that freshly-pressed white coat with newly stitched embroidery detailing your name with those two highly regarded letters after it for the whole world to finally behold. Wait. What? Finally? It came faster, was more difficult, and the process less reassuring to your unpreparedness and insecurities than you ever imagined. Are you actually ready for this? You will never be ready for this. But, this is the next step. The step that all those seasoned doctors you admire had to take at one time, too. They were once entering a hospital just as you are today, with exactly the same level of readiness you have. Think your feelings of unsteadiness, incompetency, fear, self-criticism and immense self-doubt are special? They aren’t. Just ask the intern beside you who is also putting on a brave face while squirming beneath their white coat if you do not believe me. Sadly, you won’t. You still think you are the exception with how you are processing all of this. Do not let the others fool you, even if they do come from generations of doctors.
I see those gel pens and pocket medicine references neatly organized in your pockets. Stethoscope and reflex hammer in tow. Hair neatly combed back. Glasses secured. Standing up straight to feign confidence, but with eyebrows raised and mind vigilant as if already on the defense of your skills — all that auscultating, percussing, palpating and examining over the past two years was not for nothing, kid. “Don’t worry,” those in the year above you said, “no one ever uses those skills anymore anyway.” Not until you need to at least. You will.
You wonder if anyone can tell it is your first day. They can … and will continue to assume so for at least the next couple of years. That is about how long it takes before you begin displaying the stress and grit of clinical training through the lines of your face and the stains on your white coat. You really will need to get that dry-cleaned every once in a while. There are other good things to look forward to as well — steadiness in your voice, confidence in your tone, and performing an exam with ease. A sense of assuredness and calmness will develop as you learn to simultaneously listen, field questions, and think about what to do next. You will get good at focusing on the present, but also planning ahead. Your hunch about what is going on will arrive more quickly with each new patient you meet. The volume of patients you will see will force you out of your nervous shell. More humorously, and appreciatively, you will become desensitized to sights and smells you previously were not able to stomach.
Rewind. Okay, if you are white and male, they will mistake it for your first day even when it is not. If you are female or a minority, on the other hand, people will never mistake it for your first day as a physician. Rather, many will never assume you to be a physician at all. Of course it is not the worst insult, or even an insult at all, to be called a nurse or some other vital person who works within the hospital, but it is somewhat deflating that after performing the best history and physical exam of your life you are met with a voice that rather flatly asks, “When am I going to see the doctor?” The excitement of your small triumph will be extinguished as quickly as it arrived, sprinkled with resentment and annoyance. Not exactly what you had imagined when you matriculated into medical school.
You will press onward anyway, develop a thicker skin and become less self-absorbed because of these experiences. You will get your solid streak of being seen as the treating physician. That is, until … a patient’s family member gestures to the male medical student beside you and says, “Don’t worry, this kind gentleman doctor is going to take good care of you and figure out what’s wrong.” Have you not been introducing yourself clearly? You have. Surely the embroidery with those two magical letters after your name has not already worn off? It hasn’t. Are you not standing tall enough? Are you wearing too much or too little make-up? Does the low bun at the nape of your neck not scream responsible, dedicated, serious? Does the white coat not appear as powerful and halting on you as it does on him? It doesn’t matter. You cannot control how patients reflexively view you. You can control how you respond. This will happen again and again, and again. It will soon be old news. Be courageous, compassionate, and humble despite peoples’ quick and unfounded judgments of you. Oh, and despite their skepticism and lost faith in medicine, their tendency to idealize TV doctors and fad treatments, and their ambivalence for change. Face the fallacy that just because you are a doctor people will blindly and happily follow your recommendations. The reasons which tend to counteract this one-dimensional assumption are innumerable. Bottom line? It is not about you. You are largely not responsible for why people may be untrusting or noncompliant, or whatever the new term is that sounds less pejorative.
When people do recognize you as a doctor, your presence might not inspire all warmth and loving feelings, either. Some will harbor resentment for past medical experiences, treatment or outcomes surmised as negative, or even traumatizing. Do not mistake your identified feelings of guilt for being found culpable of any of it. You are not, just as you are not responsible for the oppressive history and current state of medicine with all of its unfortunate short-comings and room for improvement. Some look for treatment elsewhere because of the system’s imperfectness. Some have capitalized and profited from it. You will learn from it and make it better.
There will be times that medicine is just like what you dreamed it to be. That brilliant upper-level resident who always knows what to say, what to order, what to do, and will patiently and humbly encourage you through your first paracentesis or some other tried-and-true procedure that you will nail. Nothing will beat the satisfaction of relieving a patient of unbearable pain so immediately through such a logical and low-cost procedure. Will all of medicine be like this? Unfortunately, no. Sorry, but it can’t be. It is often numbingly monotonous and slow, bafflingly illogical and inefficient to the point of being infuriating, and less advanced than we would like to believe. At times, impossible even. Often, unfair. More proper terms might include: “Outside of insurance plan limits,” “Inconclusive,” “Refractory to treatment,” and “End-stage.”
What you most need to swallow is this: suffering is a part of medicine. Why? Because suffering is a part of life. The cause for it is not always curable. You will suffer when you see patients suffer. Because you are human. Comforting your patient and their family is sometimes the best and only care you can provide. Do not forget to do that. But how? Ah, it is difficult, is it not? Begin grappling with the fact that medical school admissions and advancement are largely focused on high standardized test scores and GPAs — numbers which required years of study to earn, but no longer matter. Although not much emphasized in medical school, your newest expectation is to master emotional intelligence. You will not find an algorithm for that. You must shift your thinking from memorizing medical algorithms to prioritizing human connection, which means sensing what people might need from you, being informative and helpful in ways they perceive to be comforting. Remaining composed while attempting to guide them through the worst of times will help everyone to stay grounded. It is okay if you cannot always hold it together, because you will not always be able to. Be with your patients. Be with their families. Just be with them. You must allow yourself to practice tolerating others’ distress if you ever expect to accept your own. This work is not easy. Be prepared to stumble many, many times.
Back to that brilliant upper-level resident. You guessed it, they will not all be that supportive and kind. But you can be. When you get there. Yes, you will get there. One step at a time! Remember how surreal it felt to be accepted into medical school, and then matched into a residency program, and then while attending hospital orientation just a few weeks ago? You will feel that again. If you take the time during your final years of training to reflect upon your journey at least once, you will see the evolution not only your skills have taken, but you have taken. You will be the one who knows what to say, what to order, what to do. Just don’t belittle the intern beside you who does not know. Yet.
You still have that pep in your step, don’t you? Nothing can stop you. Just ask that seventh cup of coffee in your hand. Enjoy your energy now because you will have fantasies of leaving the hospital so many times. This will not mean you have turned into a bad person. You will reasonably think you can leave for the night after ordering just a few more morning labs, but your team will be covering new admissions from the ER until 7 p.m. Having to wait until 7 p.m. to leave will be the least of your worries. Count on a diabetic COPD’er coming in at 6:45 p.m. in need of admission by you. Why? Because it will be your turn to take a new patient. Your face will look and feel as fiery as the acid reflux in your esophagus from that cheeseburger and fries you just scarfed down. No one cares that it was the only edible-looking thing left in the cafeteria by the time you made it there. No one cares that you arrived at the hospital before 5 a.m. this morning. No one cares that you are expected to show up at the same time tomorrow. No one cares that your co-intern just got an easy admission two hours ago and had help from the upper-level entering orders. Your patient will care if you cut them short of a thorough work-up though. The fact that no one is watching makes the accuracy of your assessment that much more important. This will be your time to take responsibility.
How can one person master so much? The physical demand of the job, expected. The feelings one develops towards the system, fellow residents, attendings, support staff and patients? There is a reason no one is eagerly waiting in line, pouncing at, or creating opportunities to share these feelings. They are messy, confusing, complicated, and just, ehhh. Add it to the list of avoidable topics, along with having to constantly compartmentalize and categorize life and career, and then having to detangle them every once in a while. Doctors know the most intimate details of peoples’ lives, but find it hard to accept, nonetheless express and manage, their own.
Is it fair to expect one person to take ownership of it all — become an expert in medicine, but also equally proficient in connecting and comforting a variety of people, continuously considering cultural ideas and beliefs that might influence care — while staying afloat of all of the physical and emotional stuff? No, it is not fair, and even questionable whether a mere human could be so sophisticated and well-rounded to accomplish it, but the pursuit of the task is imperative. That is, if you want to provide exceptional care. Otherwise, it is not fair to patients. You can only provide as good of care as you aspire to provide. Not everyone is capable of it or models it perfectly. Those who do it well are those who have tirelessly practiced their skills. The auscultating and percussing is the easy part of this gig and even though desired outcomes are often linked with how well we connect with our patients, insurance does not prioritize quality time with patients. But, you will.
I know it is a lot. Remember that part about being human through all of this. You cannot take yourself so seriously and you must be some version of kind to yourself. Again, no one said this was going to be easy. But someone did once say that all worthwhile things require time and effort. You have already put in a lot of effort up until this point, yes, but you do not yet know effort like what you are about to exert over the next several years. Don’t get me wrong. You are not the victim here. You, your loved ones, and those who will otherwise be impacted by you are the beneficiaries of your learning experiences and knowledge to come. You will get the rest you need, be fed, and have time for relationships eventually. Your patients may not. You are privileged because you get to be a participant in this tedious, sometimes convoluted process. Even with all of its flaws, it will teach you, strengthen you, better you, move you, and leave you in a puddle of awe for what the human body can endure. The benefits are profound. First, the process will break you.
You ask if you belong in this field. You do. You wonder if you are cut out for this. You are.
Are you ever going to learn all that is necessary to practice independently? You will. And be done with learning? Maybe training, but not learning. Would you want to be in a field that offered the endpoint? Didn’t think so. You would not have it any other way. You can’t see yourself doing anything else.
Ready for tomorrow? That’s the spirit. You are equipped with a little more than yesterday and as ready as you will ever be.
Now do you feel seen?
See, you are not that special.
–A Doctor, Like You
Image source: Stethoscope by Rosmarie Voegti licensed under CC BY 2.0.
Resident Physician Contributing Writer Emeritus
Kara F. Curry, DO is a child and adolescent psychiatrist practicing in Rhode Island. She completed her psychiatry residency at the University of Louisville and her child and adolescent psychiatry fellowship at Tufts Medical Center.