We begin with the cliche: what a whirlwind. Match day has come and gone again. And with these celebrations it is hard for me not to put myself in the shoes of those ecstatic med students who are imagining (maybe a little too brightly and optimistically) the upcoming happy phase of their lives when they get to finally sign in as responding clinician for their patients. Since that moment when I yawped with joy at my own Match Day Letter, over 50% of my residency has passed…and while there is much left to learn, part of me is astonished by the amount my co-residents and I have grown in 18 short months. Below is an incomplete list of lessons and reflections I’ve compiled since the beginning of becoming a physician.

  1. Imposter syndrome is real, and permeates the culture of medicine at every level. I have realized that this is, unfortunately, inherent in medicine, for the following reason: medicine by definition involves the direct care of sick patients by providers who are prone to internal self-doubt surrounding their clinical decision. We are taught throughout medical school that there are right answers for every illness; this is reinforced by the numerous unrealistic multiple choice exams that distill each patient into a clinical vignette, where answers are either right or wrong. We enter residency primed to find the right answer or be shamed for making the wrong decision, and this is further perpetuated by individuals with strong personalities who are quick to place blame on others for “subpar decisions”. We go through residency noticing that residents, fellows, and attendings talk shit and complain about other people behind their back, and can’t help but wonder whether they whisper about your clinical judgment too. This is amplified by the fact that we haven’t yet truly escaped the evaluative phase of our training and are prone to comparing ourselves with our co-residents, many of whom will be applying into the same hyper-competitive fellowships. Unfortunately, there are no easy fixes, as the stressful work environment, the gravity of our decisions, the exhaustion of night shifts and call shifts, all contribute to the short fuses that lead to interpersonal conflicts.

  2. Along the same lines: very few medical decisions we make will save or kill a patient. There are, of course, medical problems that must be managed correctly with the right therapies; there are important clinical guidelines that need to be adhered to. These tend not to be the hardest questions we face day-to-day. In the end, the system trains us to prescribe the right medications for heart failure, infections, etc., without much issue; where providers truly make a meaningful difference will be in their approach to the socioeconomic and interpersonal issues that are relevant to a clinical case. Prescribing a diuretic to a patient in decompensated heart failure is not hard; what is hard is figuring out why they can’t take their medications at home, or how to support them when they can’t afford heart-healthy food, or when to talk about goals of care with a person who is still full code at age 90 with severe heart failure who has been admitted 5 times in 3 months. The growth in a clinician comes when they recognize those situations where they’re only rearranging deck chairs with medications, and missing the bigger picture decline in a patient’s health.

  3. The specific language we use absolutely matters in how others perceive us. Nowadays when I lead medical students and interns, I tell them what I think is not reinforced enough early in our training. Use the words “I think”, “I want to”, “let’s”, “we should” to assert an assessment and plan. As a student and intern, I often lacked the confidence to push a plan to my senior and attending, and would use words like “maybe we should”, “what do you think about”, “I feel like this is probably”, etc., which conveyed a tone of self-doubt and deference. The more time I have spent as a resident, the more I have realized that for the vast majority of cases, there is no single right answer, and that my thoughts and analyses are as valid as those of the team members I’m presenting to. As long as there is a rationale and a discussion about your reasoning leading to your plan, you should present your plan confidently.

  4. In the same vein, be confident about what you don’t know. Avoid the words “I’m not sure” for the more assertive “I don’t know”. In my experience as a student, there will be some individuals who will openly express judgment for what you do not know. What I have come to understand is this: the lack of a student or resident’s knowledge surrounding a medical scenario reflects less about their intelligence than the simple fact that they have not been exposed to the scenario before. To subject a student to shame for not knowing a medical fact is to suppress their willingness to ask questions in the future.

  5. A good leader is deliberate about fostering an environment where people feel comfortable asking questions. My strategy is to practice voicing my own questions, no matter how simple or basic, to set an example of the types of questions other people should feel comfortable asking.

  6. I have at various points in my past held opposing opinions about memorizing facts. In college, I was fully against memorizing, and believed it to be absolutely inferior to “understanding concepts”; I chose classes in mathematics that would teach me to understand things from first principles, and preferred to reason through and derive solutions over memorizing facts. In medical school, I learned quickly that this would not work for medicine and biology; there are too many unknowns to fully reason through problems, and medicine is too expansive a field to go through the exercise of first principles for every single question. Now in residency, I realize this is a more nuanced question than I had appreciated before. There are absolutely too many things in medicine to memorize, and in the vast majority of cases, it is far more important to know what to look up than it is to have the answer at the tips of your fingers. However, memory has a crucial role in acute medical situations, where knowing doses and medications for specific indications can make a life or death difference in the moment. There is no single right way to learn medicine; clinicians need to adapt their learning style to the type of medical problem at hand.

  7. There tends to be a great unspoken fear among younger residents surrounding the idea of asking for help too soon, or having too low of a threshold to consult a specialist. As an intern, my threshold for calling a rapid response or calling a code was higher than it is now, partially out of concern that what I was nervous about did not truly represent an acute medical crisis. Nowadays I have learned to trust my instincts when I feel worried about a patient, and that escalating care and asking for help early is far better than the alternative: not asking for help when you should have.

  8. Sometimes we attribute decisions to the person writing the order, and we forget that the person who placed the order was likely told to do so by a senior resident or an attending. Don’t blame an individual for a clinical decision when they were likely only the messenger.

  9. Medicine is only one aspect of life, and it is worthwhile to remember that a world outside exists – of family, friends, travel, hobbies, love. It is also worthwhile to remember that this applies not just for us, but for all of our colleagues. Our investment in our patients’ health, coupled with exhaustion and burnout, can understandably fuel animosity or conflict between colleagues (co-residents, specialty teams, etc.), but outside of the hospital we are all humans trying our best to live good and fulfilling lives. Sometimes it’s hard to remember this.