Starting medical school is one of the most exciting moments in a physicians career… but it can be a little daunting! This talk is one I gave recently to the college students in the Baylor College of Medicine Summer Surgery Program. In addition to talking about how medical school is different from college, I also included my top 10 tips for successfully making this important transition.
As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our workload. It is difficult to look forward to the dawn of the next work day.
Medical journals and blogs label this as “physician burnout” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead, we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.
Instead, we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days — interminably.
Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:
Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative, and it’s necessary.
Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.
Drink water throughout the work day.
Go to the bathroom when it is time to go and not four or even eight hours later.
Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.
Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.
Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.
Weep if you need to, even in front of others. Holding it in hurts more.
Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.
Learn how to say no gracefully and gratefully — try “not now but maybe sometime in the future and thanks for thinking of me.”
Celebrate being unscheduled and unplanned when not scheduled and planned.
Get away. Far away. Whenever possible. The backyard counts.
Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.
Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.
Start your work day on time. End your work day a little before you think you ought to.
Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.
Take a day off from caring for others to care for yourself. Even a hug from yourself counts as a hug.
Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.
Like so many others, I can’t believe the hatred and evil that has manifested itself in Orlando, Louisiana, Minnesota, Dallas, Nice and Baton Rouge. I grieve with the families and friends of those who lost their lives. I embrace those who are devoting themselves to healing this hatred and the wounds it has caused.
As someone who teaches embryology I can tell you that all of us – no matter what race, religion, sexual orientation, or gender are fearfully and wonderfully made. We all start as one cell and become human beings through an amazing dance of cells that become eyes to see, hearts to beat, arms to hold and brains to understand and love. There are no differences between us until we are born and labels are applied.
As a surgeon, I can tell you that all blood is red. I also can assure you that all hearts break equally when faced with hatred, loss or grief …. and all souls soar with birth, healing and love.
May we all become healers in this time of sorrow.
“Do what you love to do, and do it with both seriousness and lightness.”*
On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.
As I read her thoughts on how to live a creative life, I realized that there were other ideas that applied to physicians, physicians in training and others who serve:
Just show up. Every day.
“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”
Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee. Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.
But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.
“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”
“They are your patients… from the first day of medical school until you retire.
“Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”
Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.
It’s called the practice of medicine for a reason.
“It’s a simple and generous rule of life that whatever you practice, you will improve at.”
Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.
There is Peril in Perfectionism
“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”
One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.
Curiosity can overcome fear.
“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”
It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.
Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.
“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”
Your worth is not the same as your “success”.
“You can measure your worth by your dedication to your path, not by your successes or failures.”
Wow…. This one is so important.
It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.
One last thing….for medical students trying to choose a specialty – forget about finding your passion.
This is a little longer quote than the others, and mirrors a similar message in So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love .
Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.
“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.
*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!
At the most recent ACS Clinical Congress, I was really struck by a presentation on mindfulness given by Sharmila Dissanaike and asked her if she would be willing to write about the topic for wellnessrounds. To my delight she agreed!
The recent #Ilooklikeasurgeon phenomenon reminded me that times do indeed change – albeit slowly. The peak of this phenomenon happened to coincide with my talk at the American College of Surgeons on “Mindfulness for Stress Reduction and Burnout Prevention”. If you had told me 10 years ago that I would one day deliver this brief lesson in stepping off the treadmill for a few moments, I would have said you were crazy. Surgery was only for the tough, and the tough don’t need breaks (or so we thought). As a woman surgeon, it was even more important to me that no chinks show in the armor, and being a trauma surgeon proved an easy way to solidify my “street cred” despite being a 5”2’ little brown woman with long hair.
So it has taken a while for me to feel confident enough to broach such a “soft” topic in a public surgical forum. Obviously age and (a little) wisdom has probably helped, but there is also a tangible change in the prevailing culture of surgery as exemplified by the #Ilooklikeasurgeon movement and other similar initiatives; where calling for help is no longer an (automatic) sign of weakness, and the surgical community has accepted that the good old days (or bad old days, depending on your perspective) are well and truly over. The next generation of surgeons is currently being greeted with much hand wringing and wailing and gnashing of teeth, for how could a group of kids raised in this limited workhour era possibly achieve the heights of excellence that the “old school” surgical residents achieved? Since the switch to 80-hour workweek happened exactly midway through my residency, I have the privilege of a foot in both worlds, and while I agree that our training paradigms do have to change, I am not yet ready to concede that the golden age of surgery is well and truly behind us. Partly, this is because of the audience that gathered for the session at ACS. What stunned me even more than the opportunity to speak on mindfulness was the full house that gathered for this session, and the enthusiasm and interest generated by a wonderful audience of men and women of all ages, and in nearly equal proportions – it embarrasses me to admit that I had expected to be speaking to a handful of younger female surgeons. Instead, I met the 65 year old broad-based general surgeon who came because he recently lost a younger orthopedic surgeon colleague to suicide – by stabbing himself through both femoral arteries, with surgical precision of course. I met several Governors of the College, who were in the classic “grey haired” demographic, and yet optimistic and enthusiastic about the future of surgery, and the improvements to be had by focusing more on our wellness – that “healing the healer” would have tangible results not just for our own wellbeing but also that of our families and our patients, and was thus an obligation, not an option. I met young surgeons a few years out of residency/fellowship who had already recognized the need for maintaining their own mental health in order to remain functional for as long as possible in order to maximize the productivity to be gained from their long training – working less was certainly not on their priority list. There was clear recognition of the systemic problems that drive a lot of surgeon frustration with ensuing burnout – bureaucracy, being treated as interchangeable expendable cogs in a machine, electronic medical records and endless paperwork topping the list – and yet there was also an acknowledgement that adjusting internal cognitive factors was at least as important for wellbeing as it was to try and change some of the external factors.
The methods I teach are focused on building resilience and capacity – characteristics that are both innate and learned, which can be developed and expanded through meditation and other techniques. One of my favorite analogies is that a spoon of salt in a cup of coffee renders it immediately unpalatable; the same spoon in a river or swimming pool would not be noticed. The spoon of salt represents the unavoidable daily irritants in our lives – the cases that run late, the scrub tech who doesn’t know what instruments you use, the colleague who lets you down in a key meeting. The cup of coffee of course is us – or at least, where most of us start. Instead of spending our lives either trying to avoid all these frustrations (which is futile) or becoming upset when they happen, mindfulness can increase our capacity to be with them fully, accept them for what they are and yet respond thoughtfully and effectively instead of blindly and automatically reacting with anger or frustration (which usually only causes us more trouble in the long run). Over time, we develop an increased capacity to handle irritation without it placing us in a perpetual bad mood, and increased resilience to bounce back from the inevitable traumas of life, both personal and professional.
So why teach mindfulness to surgeons, when there are plenty of other things I could be doing that would probably be more directly beneficial to my career? Because I do believe that the biggest waste of potential is to take a motivated young person, put them through the grueling training to be a surgeon, set them out on a career that is of such benefit to society, and then allow them to flounder and become discouraged 5 – 10 years later, quickly discarding those hard-earned skills as they turn into full time administrators, wound care docs or some other alternate career path. Not that there isn’t value to these professions of course, and some people do realize at a late stage that they are better suited to another path – in which case all of these are excellent choices. But too often it is one bad outcome that leads to a malpractice suit, or some other event that proves just too difficult to handle, that completely derails an otherwise excellent surgeon and this lack of coping – the lack of capacity, and resilience – leads to a complete abandonment of what should be an intrinsically rewarding career.
If mindfulness, meditation and other strategies can help even one surgeon regain a wider perspective and avoid this outcome, then it will have been a worthwhile endeavor.
Dr. Dissanaike is a general surgeon with primary focus in trauma, burns and critical care, and a Professor at the Texas Tech University Health Sciences Center in Lubbock, TX. She serves as Medical Director of the Level 1 Trauma Center and Co-Director of the regional Burn Center. She has an interest in ethics and humanism, and is on the ethics committees of both the American College of Surgeons (ACS) as well as the American Burn Association.
My heart breaks for Sheryl Sandberg’s loss of her husband … and I am so grateful for her honesty, her wisdom and for the effort it took to share her journey. As I read her post on Facebook today, I realized that all of us in medicine could benefit from her thoughts as she ends sheloshim, the Jewish 30 days of mourning for the loss of a spouse.
One of the things that is so hard to teach in medical school (and all other health professions) is to honor the resilience of those we accompany on their journey through times of struggle and loss. It is so hard to let go and realize there is nothing to “fix” in these situations. Far more important than trying to convince our patients, their families or our friends that it will be “better” or that there is “hope”… we need to commit to just being there with them, and walking with them on this very human… but incredibly hard journey.
“I have learned that I never really knew what to say to others in need. I think I got this all wrong before; I tried to assure people that it would be okay, thinking that hope was the most comforting thing I could offer. A friend of mine with late-stage cancer told me that the worst thing people could say to him was “It is going to be okay.” That voice in his head would scream, How do you know it is going to be okay? Do you not understand that I might die? I learned this past month what he was trying to teach me. Real empathy is sometimes not insisting that it will be okay but acknowledging that it is not. When people say to me, “You and your children will find happiness again,” my heart tells me, Yes, I believe that, but I know I will never feel pure joy again. Those who have said, “You will find a new normal, but it will never be as good” comfort me more because they know and speak the truth.”
Thank you for your wisdom, Sheryl. We will hold you in the light.
Rabbi David Wolpe: What Sheryl Sandberg’s Post Teaches Us
“We are all just walking each other home.” Ram Dass
It’s not often that a talk completely changes the way I think about something.
I’ve been thinking and speaking about compassion fatigue for many years. I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.
We can never have too much compassion nor can true compassion result in fatigue.
Empathy and compassion are not the same thing.
Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.
Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”
Self-regulation is the key to being able to remain compassionate and this skill can be taught.
We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences. How you respond to this state determines whether you can stay present, effective and compassionate. Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.
G: Gather your attention. Take three deep breaths. Be present.
R: Recall your intention. We choose careers in medicine to help heal the sick and to reduce suffering. It’s not easy to remember this intention when we are overwhelmed. But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.
A: Attend to yourself. Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy. After gathering your attention and recalling your intention, pay attention to what is going on in your body. Watch your breath, feel where there is tension, pay attention to sensations.
C: Consider what will really serve. Moving from empathy to compassion is defined by considering the actions that will relieve suffering. Really consider the person and the situation and decide what is most likely to improve the situation.
E: Engage ethically.
“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.” Joan Halifax
I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them: Will I kill or hurt someone? Will I look stupid? What if they find out I’m not as smart as everyone else? Will I get divorced/separated/alienated from my friends? Will I gain weight? How am I going to find time to take care of myself?
What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way. The best way to manage your (healthy) fear is to have a strategy. I’ve written in the past about how to succeed as an intern. But if I were going to condense that advice into three easy rules (for every day except your day off) it would be these:
1. Read at least one section from a textbook in your field every day
2. Learn something (in detail) from at least one patient every day
3. Do something to take care of yourself every day
Read at least one section from a textbook in your field every day.
Your goal for the year should be to read a major textbook in your field cover to cover. You don’t have to buy the physical book. It’s fine if it’s on line or downloaded onto your iPad.
Once you have the book, make a list or spreadsheet of all the sections in all the chapters. For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics. When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).
The real goal is not just to read these topics, but to really learn them. So, when you read, don’t just skim. Read to learn. That means taking notes – and reviewing them.
Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.
Learn something (in detail) from at least one patient every day.
It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service. Make it a daily habit to learn in detail about one patient in your care. It will overlap nicely with your goal to read a complete textbook. When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.
One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher. When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself. Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents. They’ve been there.
Do at least one thing to take care of yourself every day.
This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day. At a minimum, though, pick one specific thing you are going to do for yourself and then do it.
Eat well
Get Some Exercise
Be social
In the next few weeks 17,000 college graduates will start the process of becoming lifelong students of medicine. Medical school is a wonderful, but at times difficult experience. Here are five “rules” that I hope will help with this exciting transition.
1. You can drink from a fire hydrant, but you’ll need to learn how.
The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college. At Baylor (where I teach) we calculate that the first year of medical school is the undergraduate equivalent of 22 hours of course work per semester. It really is like being asked to drink from a fire hydrant. You are going to have to study more, study better and actually use the time in class to learn. The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”. But these first two years are important; You are learning a new vocabulary… a new language. If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”. By the way, sometime during the first month or two of medical school you will think that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c) there is absolutely no way to read all of this material. But, like everyone who has done this before you, will discover that a) you are just as smart as everyone else (sometimes in different ways, but equally effective) b) nobody made a mistake – you really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.
2. Make your bed.
You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you. Therefore, you are already primed to sacrifice a lot of your needs for other people. Sacrifice is part of the culture of medicine. But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective. “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.
3. Act like a doctor – starting now.
We (all practicing physicians) see you as a doctor already. I know this is a really hard concept for first year medical students, but it’s absolutely true. You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years. With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well. Start thinking about your decisions, words and actions and how they might be interpreted by patients or colleagues. It’s no longer acceptable to put anything you want on YouTube, Facebook, Twitter or other social media. How you dress and act when you are in professional settings will be important. You’ll learn more specific details about professional behavior from your professors and colleagues as your training progresses, but the core values of medical professionalism start when you enter the profession, which is now.
4. Kindness matters.
It is remarkable how our paths in medicine cross over and over again. The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now. You and your classmates will be going through classes together (like you did in college), but this is different. You are starting your professional life together as well. The camaraderie that results is a gift and is also very important personally and professionally. Don’t blow off the class events. Don’t stay home to study instead of going to class. Go out of your way to meet everyone in your class and really get to know them. Cultivate and nurture these important friendships.
5. Enjoy the journey
You are about to embark on a life changing (and fulfilling) journey. This journey is a privilege and it is very, very special. Take a few minutes everyday to write down the events of the day. The first time you hear a murmur in a heart will be just that – the first time. Take a minute to record what that was like. You are going to have a lot to process as you start studying anatomy – more than just the names of the structure. “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab. There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down. When you look at them later, you’ll be glad you recorded them with words, photos, or drawings.
“Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.”
William Osler, from Teacher and Student, in Aequanimitas.
The summer is the time that the roughly 16,000 new doctors in the United States start their residency training. For all new interns, even though it doesn’t feel like it, you are ready! The first year of medical school gave you the “vocabulary” you needed for this new language. The second year gave you the “grammar.” Your rotations in the clinics taught you the “language”. Now you get to actually use it every day!
This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories. Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!). These notes and images will be precious memories in the future.
In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship:
Learn from every patient.
As an intern, you will need to know a lot of detailed information on your patients. You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said. If you have a system you developed as a 4th year medical student, great! If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring. In the era of the EMR, much of the information you need can be easily accessed… but not really organized the way you need it. If you have developed a good system that doesn’t require physical cards, please send me a message so I can see it!
That covers the information, but not the learning. Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep. Work on a system that lets you record what you are learning during your daily tasks in a way you can review later. 3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see. p.s. Don’t lose your cards!!!! (HIPAA violation)
Don’t confuse gathering information with studying information. Taking notes is a critical part of learning. Don’t just store chapters and articles in your Google drive… summarize them to review later by taking notes.
Be the doctor for your patients.
This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient. Stop every once in a while and remember that you really are their doctor. Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.
It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”. When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending. What if you were really the only doctor around? What would you do? Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.
Part of being a good doctor to your patients is to recognize your own limitations. You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is. It’s the right thing to do for the patient.
Be deliberate about learning your field.
From day one, commit to an organized plan of study to cover everything you need to learn in your field. Make a plan to read (and then study to learn) a textbook every year. Make notes that are easy to review, so you don’t have to go back to the textbook to review the material. Whatever system you use, make it easy to integrate the notes you are making in the hospital (e.g. the 3×5 card on each patient) with your organized study system. Adding articles into the mix is fine – but only after you have mastered the basics. Don’t let reading the latest finding take the place of really learning the material in the textbook.
Be kind and be part of the team.
Hard work is made easier when it’s done with your friends. You will all be tired, you will all be stressed, but be kind to each other. Staying 5 minutes more to help out a fellow intern is an investment that will help both of you. Look for ways to apply the golden rule of internship: “Help others the way you would liked to be helped”.
Make your bed.
Do this simple act every morning to remind yourself to take care of yourself. Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call. Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own well-being by improving your nutrition and working on your fitness. Nurture your relationships – make your family and friends a priority. Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.
Smile!
You have the enormous privilege of caring for other people and learning the art of medicine. Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.
Congratulations to you for all you’ve accomplished thus far! Enjoy this incredible journey!
