One Saturday morning at the Salt Lake City Veterans Affairs Medical Center, I got out of a call room bed and realized I had done it. The year everyone dreads, the year everyone says, “you just need to get through” was finally over. I had completed my write-ups on all the patients I admitted overnight. My emergency room consultation requests had been seen. I checked my pager for missed pages: nothing. I was done. I walked out to the parking lot, took a last look at the massive Wasatch Mountain Range behind me and went home. I was no longer a medical intern. I was officially a resident physician.
Waking up in scrubs that last day in a call room bed that had become as familiar as my bed at home contrasted starkly with my first day walking in my ill-fitting tie and oxford onto the inpatient psychiatric unit at the University Hospital. The number of “I don’t knows” that first day was daunting. I didn’t even know where to sit to start reading up on patient charts. Once I found out where to sit, from a technology standpoint, I realized I also didn’t know how to read: having come from a medical school where paper charting was the norm, not only had I never officially entered orders into a computer, I’d never even cycled through a computerized charting system outside of our training session the week prior. I had just been hired on the basis of a credential that took eight years after high school to earn and yet I didn’t know how to open a single patient’s chart.
As I reflect on my internship, I am amazed at the staggering difference I felt at year’s end. Not only did I learn where to sit and read, I learned when instead of sitting and reading I should be standing and running to my patients. I learned when to call more senior trainees off of whom I could bounce treatment decisions. In more serious circumstances I learned when I should call upon full Professors of medicine in the middle of the night to help weigh life-or-death decisions requiring the advice of clinicians with decades of experience.
To the uninitiated, the idea that graduated medical school students are not prepared to take full responsibility for patient care may sound surprising, if not scary. Some senior physicians rarely call new graduates “doctors” despite this being technically correct. Indeed internship is where ‘medical education’ (the foundational elements of clinical medicine are obtained) meets ‘medical training’ (wherein the actual practice of medicine begins). Residency (the years following internship) are the formative years when one earns a state medical license, takes ownership of a specialty and prepares to practice that specialty independently.
The path to this clinical independence starts in the initially awkward responsibilities of internship. Like every other intern in the country, I was tagged with the archetypal physician tether: the pager. In medical school I had a pager but no one expected actual medical knowledge attached to its plastic clip. So used was I to this state of ignorance, when my first page as an intern came through I answered as usual: “Hi, this is Arjune, the 4th year med student.” I was a full sentence into my routine when I realized my unconscious mind had yet to adjust to my recently earned degree and its portents. I was not a student anymore and couldn’t hide behind the comfort of being a paying student seeking knowledge. I was now a salaried physician, albeit lowest on the totem pole, with obligations to patients, consultations to other physicians, and the education of my own medical students. By the end of the year not only was I responding with my actual title, I was also making clinical decisions with authority.
The “M.D.” on every new graduate’s blindingly white (yet to be used) new coat speaks to two polar opposite qualities: this will forever be the apex of one’s grasp of the theoretical basis of medicine and the absolute nadir of one’s experience with respect to applying these concepts in an actual hospital. The third and fourth years of medical school bridge this gap to a certain extent with clinical rotations through the major services of a general hospital such as internal medicine, surgery, psychiatry, pediatrics and obstetrics/gynecology, but the gravity of these experiences are tempered by the fact that the word “student” is attached both in the minds of staff as well as the student. The word “student” takes on a convenient amorphousness; some days it was irritatingly pejorative and on others I clung to it with the desperation of a security blanket.
This July, roughly 20,000 newly minted M.D.s will begin internships in American hospitals. In other words, on Monday, July 1st, 2013, 20,000 people will have their blankets taken away. If you listen carefully you will almost hear the collective rush of wind and inevitable whimper.
Arjune Rama is a resident physician in psychiatry and can be reached on Twitter @arjunerama.