A letter to medical interns, in the midst of a pandemic

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In residency programs across the country, there is ongoing disappointment and a profound sense of disruption. Match Day was canceled for soon-to-be interns. Medical school and residency graduations will be strange. Finding a place to live and moving in a time of quarantine will be difficult. The only thing certain about the transition to or from residency is uncertainty. “How do I make sense of this?” is a question that everyone is asking amidst our unprecedented public health crisis, and it’s the same question physicians wrestle with innumerable times in their training. The disappointment in how medical school or training is ending is real. There is fear your training, at least how you imagined it, has been interrupted. Consider another perspective: This crisis isn’t an interruption, but an intensification. As trainees, you are uniquely positioned to learn out of the posture that many find difficult to assume day in and day out when they progress through their practice of medicine.

This pandemic provides a head start in one of the hardest aspects of being a physician: tolerating intellectual uncertainty and ambiguity. You have to wield this cumbersome task in the midst of caring for another human being who needs your help. You must learn to act in uncertainty, not in the absence of it. Hippocrates is credited for reminding us that while judgment is fallible, it also necessary. You are going to make mistakes, and you must learn from them rather than be destroyed by them.

Often it’s suggested, as it was to me, that the goal of internship is to discern the “sick” from the “not sick,” which proves much more difficult than meets the eye. “Sick” and “not sick” are not the only dual learning points; the goal should be to understand the differences between knowledge and wisdom, science and art, zeal for the new and contempt for what is old, cleverness and common sense. I have tried to understand when enduring disease is more important than curing it.

You will be tempted to treat patients as cases, and in so doing, you will be at the computer and not with the patient. Treating your documentation as a patient, and not vice versa, is paramount. At the computer, the patient becomes data, a point on a Kaplan-Meier curve. The patient’s story comes alive at the bedside. To be with the patient is to remember that the physician’s duty is not to fend off death, but rather to come alongside the patient to help make sense of, and face, what existence has become. You didn’t learn this in medical school. The antidote to lifelessness in your work is an admission that your work is always a work in progress.

I urge you to reimagine the practice of medicine and reorient yourself from thinking about residency as a job and embracing it as a calling. As the late Dr. Paul Kalanithi in When Breath Becomes Air states, “Putting lifestyle first is how you find a job — not a calling.” A calling does not confuse hard for bad. Continuous re-orientation to the profession of medicine and re-commitment to learning pushes back against stagnation, against the belief that the only cards to play are those we’ve already been dealt.

Trainees encounter social injustices, profound economic disparity, greedy business practices, and unthinkable suffering. Suffering interrupts life and reminds you that you are not the person you thought you were. We all think, physicians and patients alike, that we are our plans. When your plans are up-ended like yours have been in the last few months, as your patient’s plans unravel due to illness or the treatment thereof, you are left with only yourself. While this self is lonely and quiet, even scary, relative to your curriculum vitae or your aspirations, it is often far richer than your plans. When your first young patient dies, when you complete the death certificate of a woman who reminds you of your grandmother, and when you make a mistake, whether of omission or commission, you need to learn to lament, to simultaneously grieve and hope. To honestly cry out at tragedy will leave you unsettled, shaken. You will feel a number of different griefs – loneliness in the ICU call room; fear of wrong Lasix dose at 2 a.m.; loss of normality as you realize you can’t remember what day of the week it is– and you will have to absorb these blows while also being hit by the grief of your patients: the loss of a child, an unexpected diagnosis, a horrific side effect or complication from something that should have been routine. You have endured your own hardships, but you are not used to this kind of collective grief.

As your friends and family use words like “hero” and “gratitude,” you will ask yourself if anything you have been doing – intern things of clicking through charts, completing prior authorizations, sifting through outside hospital records, writing notes – has anything to do with being a physician. There is the potential for dissonance between what you do every day and how you put yourself forward publicly. You will long to be a type of physician, but you might not know how to bring your vision to reality.

Ultimately, our job is a difficult one. It’s hard to take usual comfort in heartwarming statistics or hollow promises of prosperity when you find yourself loving and grieving your patients. I have found there is comfort and an impenetrable hope that comes from this; this is the life-hack for training: Seek the welfare of the program, the institution, the city where you have found yourself. For in its welfare, there you will also find your welfare. As you start, finish, or continue your training, let the foundation of your vocation be marked by the virtue of hope rooted in doing the little things with great love. This rhythm will help you not only in the transition to or from training, but will also allow you thrive in the wake of this pandemic.

Sumner Abraham is an internal medicine chief resident.

Image credit: Shutterstock.com

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