A 76-year-old gentleman with a history of kidney failure, myasthenia gravis and recently diagnosed with esophageal cancer presented for evaluation of melena and hypotension.
The patient was my first admission to the medicine team as an intern, and he was as near to an ICU admission without actually being admitted to the ICU as one could come. After examining the patient, I briefly staffed with the busy attending physician, placed the orders, and wrote the H&P. When I got home later that evening, I logged in remotely, re-checked the orders and re-read my note. At 2:00 a.m., I woke up in a panic — convinced I had accidentally clicked the button on the admission order set to administer prophylactic heparin. I grabbed my phone and checked the EMR … I hadn’t.
After nine months of internship, with more days spent in fear than not, I am just beginning to understand the sources of my apprehension. Though the fears vary in content and intensity, they seem to break down into three main categories:
1. Proctors. Fear of looking like an idiot in front of the faculty physician is not a new fear when internship begins (medical school provides plenty of opportunities), but it does intensify. Expectations are higher when you cross the exciting but intellectually arbitrary line from fourth-year medical student to intern. Trying to restart warfarin on a patient with a head bleed is excusable for a newly rotating medical student, but for a “doctor” … not so much (yes, I did try this on rounds one morning). Additionally, knowing your patients well becomes more challenging when your patient load increases and your time to learn about them decreases. The less you know about your patients, the more opportunities you have to sound dumb in front of the staff.
2. Peers. Every morning at approximately 6:30 a.m. during my first internal medicine rotation, my palms would start to sweat. This autonomic response was because the more the night intern spoke about issues she had dealt with overnight, the more convinced I became that I knew less about medicine than everyone else in the room. The same physiologic phenomenon occurred during morning reports, noon lectures and even casual conversations with co-residents. The fear of being the least competent individual in your cohort is another old but persistent fear. A new group of peers, new setting, and new responsibilities almost inevitably lead to feelings of personal inadequacy.
3. Patients. As I described in the introduction, fear of doing harm to the patient is a new and profound type of fear when internship begins. As a medical student, I had certainly been nervous about looking foolish in front of the patient, but I had never seriously feared making a mistake that would significantly impact his or her health. This changed on July 1. Now when the call comes at 3:00 a.m. that your patient is hypotensive, you have to decide what to do next. In good residency programs, backup is always available, but the difficult part is knowing when to call for it. That is, you have to know what you don’t know.
When taken individually, these fears are significant but not overwhelming. When all three are present simultaneously day-in and day-out six days a week, however, they are enough to wear down even the most mentally tough intern.
This has been the most demanding and anxiety-provoking year of my life — bar none. My twenty-minute drive to work has often been spent dreading the mistakes I might make during the day ahead and longing for the commute home. In hindsight, the days were never as bad as my mind imagined them to be, but the weight of the fear and anxiety in and of themselves is a heavy burden.
How to cope (i.e., what I frequently remind myself)
At times, you will sound foolish. There is no avoiding it. The good news — so will everyone else. It’s part of the process. You will not and cannot know everything on day one. If you did, you’d be wasting your time in residency.
When you are unfamiliar with a topic being discussed on rounds, take the risk and ask about it. Better to sound a bit green and learn something new than to stay silent and not know what to do when you get that 3:00 a.m. call.
You will think your peers are smarter than you. They will likely think the opposite. The truth is: we have our strengths and weaknesses, and we all avoid speaking publicly on topics in which we are weak. When intern year is over, you will know a heck of a lot more than when you started. That’s the only comparison that matters.
Share your struggles with your co-residents. Nothing is more cathartic than swapping stories and commiserating with fellow overwhelmed interns.
Making health-impacting decisions is scary. A little fear is healthy; too much can be paralyzing. When you’re nervous, ask for help. Err on the side of caution and call that consultant when in doubt. If you have to deal with grumpy staff from time-to-time, it’s OK. If you’re calling with the patient’s interest in mind, you’re doing the right thing.
Make time for the things that bring you purpose and meaning— family, friends, faith, etc. When you feel like you have no time to spare, you probably need it more than ever. The times when I felt most overwhelmed were the times when a laugh with my wife or an encouraging word from a friend meant the most.
Autonomy is what makes residency scary. It’s also what makes it rewarding. When you make the right diagnosis, prescribe the correct treatment regimen, and the patient gets better, it feels good. Enjoy it and celebrate it.
Kirk Sidey is a transitional year resident.
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