This article is the fifth of a six-part series, written in the hope that it will be useful to those who are considering or preparing for a career in medicine, and at least entertaining and uplifting for the rest of you:
- First Decisions: Deciding to become a doctor
- Apply Yourself: Undergraduate studies
- The Academic Eating Contest: Medical school preclinical years
- Academic Vertigo and the Identity Crisis: Clinical rotations and specialty choice
- Keep Your Nose Above Water: Surviving residency
- Living the Dream: The transition from training to practice
My mother taught me to swim when I was about three or four years old at the city pool. She would stay near the edge of the pool, and I would dog paddle out a few feet and then return to the safety of the edge. One day my mom pushed away from the edge, and I followed her out into the pool thinking that she would return to the edge. But she didn’t turn around. She just kept swimming farther and farther into the pool, and I started to panic as I realized that I couldn’t go back to the edge by myself, but I couldn’t keep up with her. I called out for her to help, and I paddled along as quickly as I could. She led me through the middle of the pool and to the opposite side, and I swam the whole way. A lot of pool water ended up in my nose, and in my stomach, but I made it across the pool!
I remember feeling angry with my mom at first for scaring me like that, but this experience became an important milestone in my becoming an independent swimmer. It is also a pretty good analogy for what residency is like.
Orientation for my internship started two or three weeks after medical school graduation. During the orientation they passed out our new white lab coats, and it was interesting to watch people around the room try on their long white coats for the first time. You see, medical students wear short white coats, as in the first picture of last week’s post, but doctors wear long white coats, as in the picture above. (That picture was taken by my wife on a day when I forgot my ID badge, and she had to bring it to me. She was so proud to see me answer a page! The little girl behind me is my daughter.) Wearing a long white coat for the first time feels uncomfortably presumptive. The only differences between you as a new doctor and you as a medical student are a few weeks, a longer coat, and a couple of letters behind your name. On that first day nobody wore their new coat for more than a few seconds before quickly removing it, and I didn’t even try mine on until I got home. During my first rotation I would catch my own reflection on a glass door and be surprised to see myself in a long white coat.
Gradually you get used to being called “doctor” by everyone, and your long white coat becomes your second skin, but it takes a while to feel comfortable with it all. You spent so many years wanting to be a doctor that it takes you almost by surprise when it actually happens. This imposter feeling happens at various points during medical training, but for me the transition into internship was where it was felt most keenly.
The Doctor with Training Wheels
But you quickly learn that you are not really a doctor yet. There are long years of training yet to endure, and you are only halfway to your goal when you graduate from medical school. I remember during the cynical days of my residency saying to a younger friend who was still a medical student, “There is no light at the end of the tunnel. There are only windows, and the tunnel keeps going.”
The first year of residency is called internship, and it is different from the later years in important ways. You are always supervised by senior residents and attending physicians, who do their best to make sure that you don’t make any big mistakes.
The intern is the chief executor of the hospital team’s plan, and serves as the chief node in the flow of information between the attending physician and senior residents, and the nursing staff. It is an important job, and its faithful execution is critical to the success of the team. “Competency before efficiency” became my mantra, which was my way of saying that it was more important to do things correctly than to do them quickly.
Starting internship is a bit like merging into the fast lane on a busy metropolitan freeway for the first time in your life. I remember my first day on service, in the heart hospital. My senior resident was giving me a quick rundown of our patients at about 6:00 am, when we were suddenly interrupted by a nurse who said that a patient down the hall was pulseless. “Pulseless? Did you say pulseless?,” my senior resident asked. We ran to the room and found the patient surrounded by nurses and other personnel, and one of the residents on our team was trying to find a femoral pulse. It turned out that the patient had a “Do Not Resuscitate” order so we didn’t do CPR and she was allowed to expire without intervention. As we walked back to the nurse’s station my senior resident smiled at me and said, “Welcome to Cardio.” My first act as a medical doctor was to watch someone die. Three more patients on our service died that month. Thus began my whirlwind tour of internal medicine.
That tour took me through cardiology, nephrology, hematology, oncology, general internal medicine, infectious diseases (twice), intensive care, the emergency department, and psychiatry. I also spent a blessed outpatient month in the wound clinic, which was like a vacation. Towards the middle of the year I spent a month on the neurology consult service, which felt like an oasis because it was my only chance for the whole year to work in my chosen specialty.
This was a year of transformation, similar to the change which happens during the third year of medical school. At the beginning of the year an intern is scared to give orders to a nurse for fear of making a terrible mistake out of ignorance, but by the end of the year an intern is comfortable managing many things independently. For instance, constipation is a very common problem in hospitalized patients, and one which interns become adept at solving. One of my colleagues developed a fondness for magnesium citrate as her go-to remedy. “You drink the bottle, you poop,” she declared. Lactulose was my own favorite tool for this job. The ability to make constipated patients move their bowels is referred to as “the intern’s pride.”
The Tunnel Continues
After my intern year I moved on to the neurology department for three years of residency. The first of these years was essentially a repeat of the previous year, as the junior resident on the team has basically the same duties as an intern. The overnight call assignments were frequent that year, and the impact on family life was large. But this second internship was better than the first, because I was finally learning and practicing in my own chosen specialty. It was also nice to work on the same hospital unit every time instead of moving from place to place so much, and I actually started to learn the names of nurses, physical therapists, occupational therapists, and speech therapists that I worked with frequently.
I also formed some fast friendships with the other residents in my program, as there were only about a dozen of us in the neurology department, and I also formed good working relationships with my attending physicians. Working with the same people month after month definitely has benefits for those of us who are slow to warm up. I also preferred working in a smaller department compared to the behemoth internal medicine department.
All of this is not to say that life was peachy during residency, because it most certainly was not. It’s hard to put my finger on what the worst part of it was, though. Perhaps it was the incessant Chinese water torture of pager alerts when I was on call. Or perhaps it was the acute-on-chronic sleep deprivation and its fallout. Maybe it was the long work hours, with 70-80+ hour work weeks and as few as four days off during a calendar month.
One afternoon about an hour before an overnight call assignment I got some take out Chinese food. You never know whether you are going to have time to eat while on call, so it is smart to fill up the tank right before starting the night. My fortune cookie said, “Avoid unchallenging occupations. They waste your great talent!” I took that as a sign that my call night was going to be a rough one, which was a pretty safe bet most of the time anyway. During my overnight assignments I was the only neurologist in our massive academic referral hospital, which meant that I was the first call for neurology consults on hospital and emergency department patients, and also the first call for patients on the neurology service and for patients transferred in from other hospitals directly to our service. Most patient encounters took an hour or more to do, when you count the time spent with the patient, discussing the case with the attending physician on the phone, writing the note, and placing any orders. I had many call nights where there were not enough hours in the night to do all of the work that I was responsible for.
Residents on call have been known the throw their pagers across the room in anger, and I came close to doing that several times. There are two situations where this is most likely to happen. The first is when you are all caught up after a busy evening, and you are just about to relax a little bit. Maybe you are about to eat something for the first time in 8 hours, or maybe you just turned out the lights in your call room to get a bit of sleep. And then your pager goes off, and it is the emergency department with a new consult. The second situation is almost the opposite, when you are so swamped with work that there is just no way to add anything else to your to-do list. And then your pager goes off, and it is the emergency department with a new consult. Both of these situations can produce a sensation of sudden, boiling rage, accompanied by a rise in heart rate and blood pressure. One of the great challenges of residency is learning how to keep a lid on this feeling, stop yourself from doing something stupid, and keep working.
In the afternoons while I was nervously anticipating an overnight call assignment I would usually get an upset stomach and loose stools. When the chronic sleep deprivation became severe I used to get a sensation like my tongue was buzzing, which I simply learned to ignore. We all manifest emotional stress with physical symptoms to one degree or another.
I remember walking from the parking garage to the hospital, fighting off negative thoughts and anxieties. There was a little song I would sing to calm myself down on those days: “I’m learning, I’m getting better. I’m getting better all the time.” Without a doubt those were the most stressful years of my life so far, and you couldn’t pay me enough to do it all over again.
Speaking of not getting paid enough, you can expect that money will be tight during residency. It was nice to actually get a paycheck instead of a quarterly loan distribution, though. My starting intern salary of about $45K per year represented a nearly $100K raise over my medical school “income” which averaged -$50K per year. But it didn’t take us very long to realize that we were still poor. Too poor, in fact, to even make token payments on the $200K of student loans, which sat for 5 years accruing interest at 6.5% while I did my residency and fellowship. $45K per year was not quite a living wage for a family of six, which grew to a family of eight by the time I finished fellowship. We relied on a large federal tax return each year to keep our liquid assets in the black. As we struggled to make our paychecks last from month to month I said to my wife, “I feel like we are in an early Wright Flyer, getting just enough power to clear the trees at the end of the runway.” During these years we always paid our tithing, and the Lord kept his promise to open the windows of heaven and pour out blessings (see Malachi 3:8-12). We never went hungry, we always made our mortgage payment, and we always had a functioning vehicle to get me to work.
Residents who trained just a few years before me had it worse than I did. I remember a neurosurgery resident who told me about his internship where he worked an overnight call assignment every other night for weeks on end, working from 5:00 am until past 7:00 or 8:00 pm the next day. He would go home, get whatever sleep he could, and then do it all again starting the next morning. The bad old days truly were bad. (Why are graduate trainees called residents? Because in the old days they literally lived at the hospital. The attending physician merely attended hospital rounds.)
A sentinel event in which a patient died due to a medical error made by a sleep-deprived intern brought attention and public scrutiny to the situation. The result was for the Accreditation Council for Graduate Medical Education (ACGME) to limit the number of hours that residency programs could make their residents work. This was by and large a good thing, in my opinion. I trained under version 1 of the work hour restrictions, which I think struck a fair balance between respecting the humanity of residents and acknowledging the need to immerse them in the work in order to adequately train them in a reasonable amount of time. Version 2 went a bit too far in my opinion, and transformed internship from a trial by fire into a trial by tepid warmth. One potential consequence of making residency a bit easier is to simply delay the trainee’s ultimate competency (or their ultimate burnout) until the first few years of practice. This whole topic is quite controversial and is a moving target, but I am glad that it is at least being studied.
The Final Step
Step 3 of the United States Medical Licensing Examination (USMLE) is usually taken during residency. This is a two-day exam, consisting of about 14 hour-long sessions, each of which contained 45 multiple choice questions. That same week I also took the Residency Inservice Training Exam (RITE) for neurology, which was a 7-hour, 400-question marathon, and then I had an overnight call assignment that night. I ended the week feeling like I never wanted to read another multiple choice question for the rest of my life.
Once you pass Step 3 you can apply for and obtain your own state medical license, which is a pretty big milestone. But having your own license doesn’t really help you during residency, where you always practice under the supervision of your attending physician, and you can’t get a real job as a practicing doctor until you finish residency. This makes the experience rather anti-climactic. And there is also one more exam you have to pass, which is your specialty board examination. That usually happens during the first year or so after finishing residency. I became a board certified neurologist during my fellowship, and it made no difference to my day-to-day work at the time.
I remember USMLE Step 3 and the board exams as being not as hard or stressful as the previous exams. The MCAT and USMLE Step 1 and 2 somehow felt harder and scarier, but by the time you get to the end you sort of know what to expect from these epic exams. There is also less book studying involved in the later tests. Residents who work hard and who make a habit of learning every day should have no problem passing their specialty boards.
The Day the Music Died
During my college years I spent a lot of time recording music, and I tried to keep doing this during medical school although my output slowed down. But when residency started there was just no competing with the time demands of my work. Not only did I stop recording, but I almost stopped playing guitar at all. There wasn’t time enough to sleep; how was I supposed to find time for a hobby? I remember the day when I decided to give up on recording my album, even though I only had three songs finished and I hadn’t even started on the title track.
How could I give up on my music? If you had told me ten years earlier that I would one day set aside my music for more important interests, I would not have believed you. “What could be more important than my music?,” I might have retorted. But it was a matter of survival. I felt like I was caught in a trap, and was gnawing off my own limb to save my life. This is what residency will do to you. Don’t expect to make it through without pruning off a few branches of your life. (But don’t worry – you can probably graft them back in later if you want to. Read the next post in the series to find out how.)
First Things First
There were two branches which I stubbornly refused to prune, however. The first was my family, which was the main reason I was doing all this work in the first place. I was a husband and a father for years before I became a doctor, and as much as I could I tried to give my family the time and attention they deserved.
I should admit right now that these efforts failed, often. One afternoon after a particularly brutal overnight call my three year old kid hurt his lip somehow, and was bleeding all over the place. My wife brought him into the bedroom to get my help and advice, but she could not get me to wake up. “Alan, do you think this needs stitches? He split his lip. Alan? Alan!” Not even a screaming, flailing little kid on the bed right next to me could wake me from the post-call sleep of death.
During those years my wife became very independent, and I was impressed by some of the things she taught herself to do. One day I came home and found that she had removed the toilet from the floor in order to pull out the toy that got wedged inside it when some kid tried to flush it down. (The toy turned out to be a miniature pink plastic dollhouse toilet.) “Don’t worry, I can put the toilet back on,” she confidently said as I gazed worriedly at the hole in the floor. “I watched a YouTube video about it.”
There were occasional weekends and holidays together, and we took a few short vacations. We once visited the Church history sites in western New York, staying at a state park on one of the Finger Lakes for a couple of nights, and stopped by Niagara Falls on the way home. That is still remembered as one of our best family vacations.
I have heard of couples that sacrifice to make it through residency together, but then separate or divorce once the hard times are over. That is a tragedy! The stressful and lean years of medical training were a time of growth for our family, and we endured them together. Our experiences were different, but my wife and I both contributed to the effort and I consider her an equal partner with an equal share in the benefits of our work.
The second branch which I refused to prune off is actually the main trunk of the tree — my faith in God. Without my faith I am nothing, and all of the branches die. Residency did its best to suffocate my religion, but with deliberate effort and divine intervention my faith actually came out ahead.
Early in my internship I received a calling to teach the adult Sunday school class at church. I shared the assignment with two other people, and between the three of us we were able to cover every Sunday, with me teaching once or twice per month. This assignment continued for four years, until my weekend schedule improved during fellowship. Teaching Sunday school was the perfect assignment for me, as it kept me studying and pondering over the scriptures frequently, and praying for help to teach with the Spirit.
But there were sometimes long stretches when I was unable to attend church for a month or more. These weeks would wear on my soul. In the middle of one of these long months I was listening to the Missa Brevis in A Major, BWV 234 by Johann Sebastian Bach in the car while I drove to work. As I parked the car I was struck by a sudden desire to know what the Latin words meant, and because I was a bit early that morning I opened the liner notes of the CD and read the English translation as I listened to the Gloria (found at 6:17 in the recording linked to above):
“Glory be to God on high (Glória in excélsis Deo)
And in earth peace, goodwill towards men, (et in terra pax homínibus bonæ voluntátis)
We praise thee, we bless thee, (Laudámus te, benedícimus te)
we worship thee, we glorify thee, (adorámus te, glorificámus te,)
we give thanks to thee, for thy great glory (grátias ágimus tibi propter magnam glóriam tuam)”
As I heard these worshipful and beautiful praises I was struck with a feeling of love and gratitude for God and I wanted to join the choir in their worship of him. My heart seemed to melt, and then glow, and my weary eyes filled with tears. The Lord was lifting me above the drudgery and stress of my life and holding me in his arms for a moment. The love of the Lord and of my wife helped me make it through those years.
Residency is Act II of a trilogy, where the hero is fraught with setbacks and the forces of opposition seem to prevail. This is indeed a dark time, but don’t give in to despair. Act III is coming next, in which our hero perseveres, overcomes, and conquers!
Whatever your trial may be, please hold on to your faith and don’t let go. Faith in God leads to hope, and this “maketh an anchor to the souls of men, which would make them sure and steadfast, always abounding in good works, being led to glorify God” (Ether 12:4). I promise that you can make it through whatever difficulties come your way, if you hold on to your faith.
Part 1 of a medical education memoir: Deciding to become a doctor.
Part 2 of a medical education memoir: Thoughts and memories about undergraduate studies and applying to medical school.
Part 3 of a medical education memoir: Thoughts and memories about the first two years of medical school
Part 4 of a medical education memoir: Thoughts and memories about medical school clinical rotations, specialty choice, and applying to residency.
Part 6 of a medical education memoir: Adventures and lessons from my first years in practice
An empirical approach to COVID-19 public policy, medicine, and matters of faith.
Thoughts on risk management in medicine, life, and faith.
Testimonies develop like technology: cumulatively, iteratively, stepwise.