Hi all,

So it’s Memorial Day, and coincidentally I am in the process of finishing my last inpatient shift of residency. I have decided to take a moment here to reflect on my training and what I’ve learned. I feel pretty good about what I’ve written here, and I think it could be interesting (and hopefully even helpful) to physicians at all levels of training. But it’s not about evidence and trials, hot or otherwise, so feel free to click on by if a more personal essay isn’t your speed. There will be a standard post up tomorrow! The cystic fibrosis thing, finally. Promise. In the meantime, I hope you enjoy this. I enjoyed writing it.

Please forgive the inherent hubris of someone who has been a doctor for all of three years doling out advice. But being so close to my residency gives me a perspective that may fade with time, so I believe there is value to writing this now. I hope it helps those who take the time to read.

The End of the Beginning

I came in to work last night for a liquid oncology night float shift, on which Penn residents care for some of the sickest patients anyone should ever care to meet. Nobody has a normal white count — there are either zero or ≥ 2 numbers before the decimal, no exceptions. I think it’s hospital policy. But I was not nervous. After three years of this, three years of people trying to die in creative ways and my friends and I trying to stop them, I have no nervousness left. There is just nothing left for the hospital to throw at me.

I had an intern on this service, which is great, because I still have PTSD-like symptoms from my own intern year every time my phone rings. Better for someone else to take the calls. My intern, who coincidentally has the dubious honor of inheriting my primary care patient panel next year, was someone with whom I have worked before and is someone I trust. We’ll call him Dan, mostly because his name is Dan.

“Dan,” I said, trying to use his name as many times as possible over the course of a minute, “what do you want to learn tonight?” I like to teach. It makes me feel smart.

Dan thought for a second. “Do you… do you have any wisdom you’ve accumulated at the end of third year? How should I learn medicine? What do you wish you had done differently?”

It was a good question (three, technically), and I felt like I should have a concise answer. But I was really looking for “Hey, can we talk about the cytogenetics of AML?” more than “How should I best use my time in residency to become a doctor?” The Uptodate page for the latter is decidedly sparse. But, it’s not like I have given this no thought to date. And of all I have learned in three years going from newly minted MD to someone who can unselfconsciously call himself a doctor, the most important thing couldn’t be said to be medical knowledge per se. Here it is:

Don’t burn out.

Brilliant, I know. You’re welcome! I’ll see myself out.

But the truth is that nothing else is quite as important for your development as a physician as maintaining your passion for what you do, and burnout is the ultimate destruction of that passion. Medicine as a profession makes it almost impossible not to learn something new every day, unless you are too emotionally exhausted to do so. Every single patient encounter raises a new question, and with the vast expanse of resources now available within seconds we can find new and precise answers faster than ever before. It’s exciting, and that excitement drives what we do here at IM HEAT and in our day-to-day work. As long as you show up every day ready to work and to learn, with a desire and will to help your patients, you will be a good doctor. The more specific “hows” of this process, which resident bulletin you read or what source you first turn to to refresh your memory on a given disease process (hint: it’s Wikipedia), these things are so much less important than this — cultivate your passion for medicine and let that drive your learning.

So, don’t burn out. But as that answer is impressively unsatisfying to those looking for implementable advice, I have tried to describe my own learning on this in a more concrete way. I’ve distilled this into three points, because three is a good number of things for a list.

1. Hold yourself to a high standard, but make sure it is your standard.

Impostor syndrome is a real problem for all of us. The job is impossibly hard, and you will frequently wonder if you are doing it “well enough.” This gets much, much more pronounced when someone gives you feedback that isn’t exactly glowing. But real feedback, feedback with teeth that gives you better insight into your own shortcomings, is the best possible opportunity for growth.

As an intern, I had a general medicine rotation with an attending who just seemed to hate me. Everything I did was wrong. I was somehow the antithesis of everything she believed was right and good in medicine. To her credit, she gave me regular, in-depth feedback sessions in which she described how I could do better in her eyes.

When confronted with an inventory of one’s shortcomings, one natural response is to shut down emotionally. Try not to cry, just wait for it to pass. It is inherently painful to go over things you have done wrong, especially when there is the possibility that they have impacted the lives of real people. We all know someone who has closed themselves off to the opinions of others as a means of protecting their ego, and I sympathize. When you are sleep deprived, overwhelmed, and emotionally fragile, it is easy not to listen. And yet it is important that you do.

What I have learned is this: be mindful of the fact that feedback always has at least as much to do with the person giving it as it does the person getting it. Appreciate the insight that feedback has into your practice and into ways you might improve it, but do not feel obligated to accept on its face the conclusion that you need to do things in a certain different way.

The standard that matters is your own. If you are honest with yourself and believe that you are busting your ass as hard as anyone could be expected to do, are giving a good faith effort at getting better every day and giving your patients the care they deserve, that is enough. Carry that spark of assurance around with you. It can allow you enough resilience in the face of negative feedback to neither shut down and stop listening nor break down and cry, but rather to say “This person sees a problem. How can that perception inform ways in which I can modify my practice to get better?”

And if you look at yourself in the mirror and just can’t be sure that you’re giving the effort the job deserves? Talk to your mentors and really seek out advice. Because if you aren’t sure you’re doing a good enough job, that’s normal. But if you aren’t sure you’re putting in the effort you should be, that could be a sign that you need help.

2. If you don’t like a patient, be sure that you love them.

It’s corny, but it is the patients that keep us going. The people we help are the reason we are here. When these patients are nice, kind people, it’s easy to remember why we do what we do. But if you allow yourself to only like the patients it’s easy to like, you will resent the patients who are manipulative, who take you for granted, or who are just, for lack of a better word, jerks. And there are plenty of them, as jerks are a well-represented demographic among human beings.

If you start disliking the jerks, resenting the time you spend with them, you lose the feelings of generativity that the job should bring. You feel your time with them is wasted time. And then even though you continue to have wonderful human beings as patients, you start noticing only the jerks. You start perseverating on how the people you care for don’t appreciate it. If this doesn’t sound familiar, I don’t believe you went through a medicine residency.

This is toxic, and the only solution is to love the jerks too. Everyone can be humanized, and this is all the more important when you don’t immediately sympathize with them. Everyone has a story, and if you learn these stories you will cultivate your empathy. Ask non-medical questions. Ask about their military service, their family, their job. Find a connection. Do it for them, but most importantly do it for you. Because if you don’t love the people you care for, the lengths you go to care for them will start to feel like an undue burden, and you will burn out.

Yes, I’m saying that empathy is a selfish act here. That’s OK — you get credit for caring for others even if you’re doing it for you.

3. The hospital can only eat what you feed it.

There’s a Scrubs episode in which the hospital itself is depicted as a monster, dedicated to consuming the lives of all who enter. Most of my life can be described by various Scrubs episodes, as can most of life in general. The hospital eats sleep, healthy lifestyles, and more than a few relationships. It will eat anything. But it can only eat what you feed it.

Because we care for real people, we can have a tendency to stay late and do more, to avoid signing things out to our colleagues, to sacrifice ever more of our own time to patient care (because sometimes 80 hours a week just isn’t enough). But a great man once said to me “The longer you stay, the longer you’re here.” You have to do this job well for about 50 years. If you start to feel it sucking away at things you care about, at time with your family, at your own health, you will resent it and burn out. You owe it to the people you care for to avoid this, not only for your own sake but for the sake of continuing to provide excellent care over the long-term.

So, sign out a sick patient. Stay and make sure the transition is smooth, but don’t stay to care for the patient. There are other doctors for that. Go see your kids, have dinner with your boyfriend, see your sister while she’s in town. This will make you a happier human, which will make you a better doctor. The hospital may try to take these things from you, but it cannot do so unless you are complicit in the theft. Leave. The damn. Hospital.

The Best Job in the World

So: hold yourself to a high standard that empowers you to take others’ feedback as formative rather than judgmental, care about your patients as people especially when it is difficult to do so, and protect your personal life so that you can continue to give of yourself to others. That is the wisdom I have gained, such as it is.

And one bonus point, though one that I doubt anyone needs to hear: make sure you are uncomfortable at least once a day. If the job doesn’t challenge you, you’re doing it wrong. Intentional practice means pushing yourself just past where you know you can go, and it’s the only way to get better.

Being a doctor is hard, but the field is blessed with a ton of resources and support to help you get better at it every day. The only way you can really fail at this is if you stop trying, and the most common reason to stop trying is burnout. Keep the inner spark of your own self-assurance lit, love your patients (especially when it’s hard), and preserve your sanity for the marathon that is lifelong learning in medicine

It is a privilege to have a job worth doing well. And a job that’s never boring is invaluable. But man. It is hard.

I can’t think of anything else I would rather do